| Dental Cleaning - Adult | $106 | 0% | $106 | 
Medium |
| Dental Cleaning - Child | $75 | 0% | $75 |
Medium |
| Dental Exam - Comprehensive | $100 | 0% | $100 |
Medium |
| Dental Exam - Periodic, Established Patient | $55 | 0% | $55 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $197 | 0% | $197 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $335 | 0% | $335 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $172 | 0% | $172 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $335 | 0% | $335 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $212 | 0% | $212 |
Medium |
| Flouride - Topical Varnish Application | $63 | 0% | $63 |
Medium |
| Maintenance Therapy - Periodontal | $166 | 0% | $166 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $274 | 0% | $274 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $86 | 0% | $86 |
Medium |
| Root Canal - Anterior Tooth | $1,078 | 0% | $1,078 |
Medium |
| Root Canal - Bicuspid Tooth | $1,273 | 0% | $1,273 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $55 | 0% | $55 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $217 | 0% | $217 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
Medium |
| X-Ray - Complete Intraoral Series | $167 | 0% | $167 |
Medium |
| X-Ray - Four Images, Bitewings | $77 | 0% | $77 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $33 | 0% | $33 |
Medium |
| X-Ray - Two Images, Bitewings | $61 | 0% | $61 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $144 | 0% | $144 |
Medium |
