| Dental Cleaning - Adult | $137 | 0% | $137 | 
Medium |
| Dental Cleaning - Child | $137 | 0% | $137 |
Medium |
| Dental Exam - Comprehensive | $95 | 0% | $95 |
Medium |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $158 | 0% | $158 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $299 | 0% | $299 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $242 | 0% | $242 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $158 | 0% | $158 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $168 | 0% | $168 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $294 | 0% | $294 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $210 | 0% | $210 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $221 | 0% | $221 |
Medium |
| Fluoride - Topical Application | $74 | 0% | $74 |
Medium |
| Maintenance Therapy - Periodontal | $173 | 0% | $173 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $252 | 0% | $252 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | 0% | $95 |
Medium |
| Root Canal - Anterior Tooth | $840 | 0% | $840 |
Medium |
| Root Canal - Bicuspid Tooth | $893 | 0% | $893 |
Medium |
| Root Canal - Molar | $1,628 | 0% | $1,628 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | 0% | $74 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $168 | 0% | $168 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $42 | 0% | $42 |
Medium |
| X-Ray - Complete Intraoral Series | $242 | 0% | $242 |
Medium |
| X-Ray - Four Images, Bitewings | $105 | 0% | $105 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
Medium |
| X-Ray - Two Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $189 | 0% | $189 |
Medium |
