| Dental Cleaning - Adult | $101 | 0% | $101 | 
Medium |
| Dental Cleaning - Child | $82 | 0% | $82 |
Medium |
| Dental Exam - Comprehensive | $84 | 0% | $84 |
Medium |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $166 | 0% | $166 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $226 | 0% | $226 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $193 | 0% | $193 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $162 | 0% | $162 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $186 | 0% | $186 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $309 | 0% | $309 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $198 | 0% | $198 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $242 | 0% | $242 |
Medium |
| Flouride - Topical Varnish Application | $45 | 0% | $45 |
Medium |
| Fluoride - Topical Application | $43 | 0% | $43 |
Medium |
| Maintenance Therapy - Periodontal | $149 | 0% | $149 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $259 | 0% | $259 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $81 | 0% | $81 |
Medium |
| Root Canal - Anterior Tooth | $890 | 0% | $890 |
Medium |
| Root Canal - Bicuspid Tooth | $894 | 0% | $894 |
Medium |
| Root Canal - Molar | $1,196 | 0% | $1,196 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $57 | 0% | $57 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $180 | 0% | $180 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $25 | 0% | $25 |
Medium |
| X-Ray - Complete Intraoral Series | $144 | 0% | $144 |
Medium |
| X-Ray - Four Images, Bitewings | $68 | 0% | $68 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
Medium |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $127 | 0% | $127 |
Medium |
