| Dental Cleaning - Adult | $137 | 0% | $137 | 
Medium |
| Dental Cleaning - Child | $120 | 0% | $120 |
Medium |
| Dental Exam - Comprehensive | $120 | 0% | $120 |
Medium |
| Dental Exam - Periodic, Established Patient | $76 | 0% | $76 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $242 | 0% | $242 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | 0% | $326 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $309 | 0% | $309 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $236 | 0% | $236 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $236 | 0% | $236 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $383 | 0% | $383 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $289 | 0% | $289 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $309 | 0% | $309 |
Medium |
| Flouride - Topical Varnish Application | $53 | 0% | $53 |
Medium |
| Fluoride - Topical Application | $69 | 0% | $69 |
Medium |
| Maintenance Therapy - Periodontal | $212 | 0% | $212 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $366 | 0% | $366 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $113 | 0% | $113 |
Medium |
| Root Canal - Anterior Tooth | $1,029 | 0% | $1,029 |
Medium |
| Root Canal - Molar | $1,523 | 0% | $1,523 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $83 | 0% | $83 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $260 | 0% | $260 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $20 | 0% | $20 |
Medium |
| X-Ray - Complete Intraoral Series | $189 | 0% | $189 |
Medium |
| X-Ray - Four Images, Bitewings | $95 | 0% | $95 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $47 | 0% | $47 |
Medium |
| X-Ray - Two Images, Bitewings | $76 | 0% | $76 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $160 | 0% | $160 |
Medium |
