| Dental Cleaning - Adult | $103 | 0% | $103 | 
Medium |
| Dental Cleaning - Child | $79 | 0% | $79 |
Medium |
| Dental Exam - Comprehensive | $100 | 0% | $100 |
Medium |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $190 | 0% | $190 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $313 | 0% | $313 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $254 | 0% | $254 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $240 | 0% | $240 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $190 | 0% | $190 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $313 | 0% | $313 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $224 | 0% | $224 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $254 | 0% | $254 |
Medium |
| Flouride - Topical Varnish Application | $53 | 0% | $53 |
Medium |
| Fluoride - Topical Application | $71 | 0% | $71 |
Medium |
| Maintenance Therapy - Periodontal | $149 | 0% | $149 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | 0% | $88 |
Medium |
| Root Canal - Anterior Tooth | $821 | 0% | $821 |
Medium |
| Root Canal - Bicuspid Tooth | $926 | 0% | $926 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $202 | 0% | $202 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $16 | 0% | $16 |
Medium |
| X-Ray - Complete Intraoral Series | $149 | 0% | $149 |
Medium |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
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 | $221 | 0% | $221 |
Medium |
