| Dental Cleaning - Adult | $109 | 0% | $109 | 
Medium |
| Dental Cleaning - Child | $85 | 0% | $85 |
Medium |
| Dental Exam - Comprehensive | $99 | 0% | $99 |
Medium |
| Dental Exam - Periodic, Established Patient | $56 | 0% | $56 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $185 | 0% | $185 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $290 | 0% | $290 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $227 | 0% | $227 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $154 | 0% | $154 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $166 | 0% | $166 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $322 | 0% | $322 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $228 | 0% | $228 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $285 | 0% | $285 |
Medium |
| Fluoride - Topical Application | $54 | 0% | $54 |
Medium |
| Maintenance Therapy - Periodontal | $152 | 0% | $152 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $255 | 0% | $255 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $87 | 0% | $87 |
Medium |
| Root Canal - Bicuspid Tooth | $1,300 | 0% | $1,300 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $67 | 0% | $67 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $191 | 0% | $191 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $22 | 0% | $22 |
Medium |
| X-Ray - Complete Intraoral Series | $197 | 0% | $197 |
Medium |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $28 | 0% | $28 |
Medium |
| X-Ray - Two Images, Bitewings | $56 | 0% | $56 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $133 | 0% | $133 |
Medium |
