| Dental Cleaning - Adult | $155 | 0% | $155 | 
Medium |
| Dental Cleaning - Child | $120 | 0% | $120 |
Medium |
| Dental Exam - Comprehensive | $113 | 0% | $113 |
Medium |
| Dental Exam - Periodic, Established Patient | $78 | 0% | $78 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $221 | 0% | $221 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $299 | 0% | $299 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $234 | 0% | $234 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $223 | 0% | $223 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $242 | 0% | $242 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $364 | 0% | $364 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $261 | 0% | $261 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $303 | 0% | $303 |
Medium |
| Flouride - Topical Varnish Application | $74 | 0% | $74 |
Medium |
| Maintenance Therapy - Periodontal | $212 | 0% | $212 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $395 | 0% | $395 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $118 | 0% | $118 |
Medium |
| Root Canal - Anterior Tooth | $1,268 | 0% | $1,268 |
Medium |
| Root Canal - Bicuspid Tooth | $1,548 | 0% | $1,548 |
Medium |
| Root Canal - Molar | $1,999 | 0% | $1,999 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $88 | 0% | $88 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $267 | 0% | $267 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
Medium |
| X-Ray - Complete Intraoral Series | $237 | 0% | $237 |
Medium |
| X-Ray - Four Images, Bitewings | $99 | 0% | $99 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $76 | 0% | $76 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $173 | 0% | $173 |
Medium |
