| Dental Cleaning - Adult | $126 | 0% | $126 | 
Medium |
| Dental Cleaning - Child | $99 | 0% | $99 |
Medium |
| Dental Exam - Comprehensive | $144 | 0% | $144 |
Medium |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $266 | 0% | $266 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $413 | 0% | $413 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $338 | 0% | $338 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $247 | 0% | $247 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $266 | 0% | $266 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $413 | 0% | $413 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $300 | 0% | $300 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $338 | 0% | $338 |
Medium |
| Flouride - Topical Varnish Application | $56 | 0% | $56 |
Medium |
| Fluoride - Topical Application | $56 | 0% | $56 |
Medium |
| Maintenance Therapy - Periodontal | $176 | 0% | $176 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $357 | 0% | $357 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $117 | 0% | $117 |
Medium |
| Root Canal - Bicuspid Tooth | $1,318 | 0% | $1,318 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | 0% | $74 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $244 | 0% | $244 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | 0% | $36 |
Medium |
| X-Ray - Complete Intraoral Series | $257 | 0% | $257 |
Medium |
| X-Ray - Four Images, Bitewings | $98 | 0% | $98 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | 0% | $46 |
Medium |
| X-Ray - Two Images, Bitewings | $69 | 0% | $69 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $184 | 0% | $184 |
Medium |
