| Dental Cleaning - Adult | $89 | 0% | $89 | 
Medium |
| Dental Cleaning - Child | $72 | 0% | $72 |
Medium |
| Dental Exam - Comprehensive | $92 | 0% | $92 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $191 | 0% | $191 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $303 | 0% | $303 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $227 | 0% | $227 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $163 | 0% | $163 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $191 | 0% | $191 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $303 | 0% | $303 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $205 | 0% | $205 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $234 | 0% | $234 |
Medium |
| Flouride - Topical Varnish Application | $42 | 0% | $42 |
Medium |
| Fluoride - Topical Application | $42 | 0% | $42 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $217 | 0% | $217 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $85 | 0% | $85 |
Medium |
| Root Canal - Anterior Tooth | $763 | 0% | $763 |
Medium |
| Root Canal - Bicuspid Tooth | $895 | 0% | $895 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | 0% | $61 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $177 | 0% | $177 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $25 | 0% | $25 |
Medium |
| X-Ray - Complete Intraoral Series | $163 | 0% | $163 |
Medium |
| X-Ray - Four Images, Bitewings | $70 | 0% | $70 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $28 | 0% | $28 |
Medium |
| X-Ray - Two Images, Bitewings | $53 | 0% | $53 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $123 | 0% | $123 |
Medium |
