| Dental Cleaning - Adult | $144 | 0% | $144 | 
Medium |
| Dental Cleaning - Child | $127 | 0% | $127 |
Medium |
| Dental Exam - Comprehensive | $116 | 0% | $116 |
Medium |
| Dental Exam - Periodic, Established Patient | $80 | 0% | $80 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $221 | 0% | $221 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $414 | 0% | $414 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $303 | 0% | $303 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $221 | 0% | $221 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | 0% | $221 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $414 | 0% | $414 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $303 | 0% | $303 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $303 | 0% | $303 |
Medium |
| Fluoride - Topical Application | $66 | 0% | $66 |
Medium |
| Maintenance Therapy - Periodontal | $221 | 0% | $221 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $414 | 0% | $414 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $93 | 0% | $93 |
Medium |
| Root Canal - Anterior Tooth | $1,158 | 0% | $1,158 |
Medium |
| Root Canal - Bicuspid Tooth | $1,433 | 0% | $1,433 |
Medium |
| Root Canal - Molar | $1,709 | 0% | $1,709 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $265 | 0% | $265 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $40 | 0% | $40 |
Medium |
| X-Ray - Complete Intraoral Series | $308 | 0% | $308 |
Medium |
| X-Ray - Four Images, Bitewings | $104 | 0% | $104 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | 0% | $46 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $204 | 0% | $204 |
Medium |
