| Dental Cleaning - Adult | $179 | 0% | $179 | 
Medium |
| Dental Cleaning - Child | $126 | 0% | $126 |
Medium |
| Dental Exam - Comprehensive | $200 | 0% | $200 |
Medium |
| Dental Exam - Periodic, Established Patient | $68 | 0% | $68 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $368 | 0% | $368 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $341 | 0% | $341 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $341 | 0% | $341 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $415 | 0% | $415 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $354 | 0% | $354 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $354 | 0% | $354 |
Medium |
| Flouride - Topical Varnish Application | $95 | 0% | $95 |
Medium |
| Maintenance Therapy - Periodontal | $179 | 0% | $179 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $152 | 0% | $152 |
Medium |
| Root Canal - Bicuspid Tooth | $2,310 | 0% | $2,310 |
Medium |
| Root Canal - Molar | $2,625 | 0% | $2,625 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $415 | 0% | $415 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
Medium |
| X-Ray - Complete Intraoral Series | $231 | 0% | $231 |
Medium |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $63 | 0% | $63 |
Medium |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $205 | 0% | $205 |
Medium |
