| Dental Cleaning - Adult | $122 | 0% | $122 | 
Medium |
| Dental Cleaning - Child | $97 | 0% | $97 |
Medium |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $222 | 0% | $222 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $414 | 0% | $414 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $298 | 0% | $298 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $214 | 0% | $214 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $222 | 0% | $222 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $414 | 0% | $414 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $258 | 0% | $258 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $298 | 0% | $298 |
Medium |
| Flouride - Topical Varnish Application | $51 | 0% | $51 |
Medium |
| Fluoride - Topical Application | $51 | 0% | $51 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | 0% | $100 |
Medium |
| Root Canal - Anterior Tooth | $1,403 | 0% | $1,403 |
Medium |
| Root Canal - Bicuspid Tooth | $1,112 | 0% | $1,112 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | 0% | $68 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $225 | 0% | $225 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
Medium |
| X-Ray - Complete Intraoral Series | $175 | 0% | $175 |
Medium |
| X-Ray - Four Images, Bitewings | $87 | 0% | $87 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
Medium |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $161 | 0% | $161 |
Medium |
