| Dental Cleaning - Adult | $101 | 0% | $101 | 
Medium |
| Dental Cleaning - Child | $78 | 0% | $78 |
Medium |
| Dental Exam - Comprehensive | $84 | 0% | $84 |
Medium |
| Dental Exam - Periodic, Established Patient | $46 | 0% | $46 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $176 | 0% | $176 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $215 | 0% | $215 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $188 | 0% | $188 |
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 | $337 | 0% | $337 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $198 | 0% | $198 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $259 | 0% | $259 |
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 | $267 | 0% | $267 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $87 | 0% | $87 |
Medium |
| Root Canal - Bicuspid Tooth | $961 | 0% | $961 |
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 | $170 | 0% | $170 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
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 | $30 | 0% | $30 |
Medium |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $120 | 0% | $120 |
Medium |
