| Dental Cleaning - Adult | $105 | 0% | $105 | 
Medium |
| Dental Cleaning - Child | $85 | 0% | $85 |
Medium |
| Dental Exam - Comprehensive | $104 | 0% | $104 |
Medium |
| Dental Exam - Periodic, Established Patient | $55 | 0% | $55 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $216 | 0% | $216 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $266 | 0% | $266 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $214 | 0% | $214 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $197 | 0% | $197 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $216 | 0% | $216 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $344 | 0% | $344 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $237 | 0% | $237 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $273 | 0% | $273 |
Medium |
| Flouride - Topical Varnish Application | $44 | 0% | $44 |
Medium |
| Maintenance Therapy - Periodontal | $311 | 0% | $311 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $90 | 0% | $90 |
Medium |
| Root Canal - Molar | $1,219 | 0% | $1,219 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $66 | 0% | $66 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $214 | 0% | $214 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
Medium |
| X-Ray - Complete Intraoral Series | $153 | 0% | $153 |
Medium |
| X-Ray - Four Images, Bitewings | $76 | 0% | $76 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
Medium |
| X-Ray - Two Images, Bitewings | $57 | 0% | $57 |
Medium |
