| Dental Cleaning - Adult | $128 | 0% | $128 | 
Medium |
| Dental Cleaning - Child | $115 | 0% | $115 |
Medium |
| Dental Exam - Comprehensive | $129 | 0% | $129 |
Medium |
| Dental Exam - Periodic, Established Patient | $66 | 0% | $66 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | 0% | $208 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $344 | 0% | $344 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $264 | 0% | $264 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $167 | 0% | $167 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $233 | 0% | $233 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $391 | 0% | $391 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | 0% | $271 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $321 | 0% | $321 |
Medium |
| Flouride - Topical Varnish Application | $57 | 0% | $57 |
Medium |
| Fluoride - Topical Application | $69 | 0% | $69 |
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 | $113 | 0% | $113 |
Medium |
| Root Canal - Anterior Tooth | $1,323 | 0% | $1,323 |
Medium |
| Root Canal - Molar | $1,785 | 0% | $1,785 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $76 | 0% | $76 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $229 | 0% | $229 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
Medium |
| X-Ray - Complete Intraoral Series | $189 | 0% | $189 |
Medium |
| X-Ray - Four Images, Bitewings | $95 | 0% | $95 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $45 | 0% | $45 |
Medium |
| X-Ray - Two Images, Bitewings | $68 | 0% | $68 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $154 | 0% | $154 |
Medium |
