| Dental Cleaning - Adult | $122 | 0% | $122 | 
Medium |
| Dental Cleaning - Child | $120 | 0% | $120 |
Medium |
| Dental Exam - Comprehensive | $103 | 0% | $103 |
Medium |
| Dental Exam - Periodic, Established Patient | $74 | 0% | $74 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | 0% | $208 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $359 | 0% | $359 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | 0% | $265 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $174 | 0% | $174 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $212 | 0% | $212 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $391 | 0% | $391 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $247 | 0% | $247 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $321 | 0% | $321 |
Medium |
| Flouride - Topical Varnish Application | $57 | 0% | $57 |
Medium |
| Fluoride - Topical Application | $57 | 0% | $57 |
Medium |
| Maintenance Therapy - Periodontal | $167 | 0% | $167 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $303 | 0% | $303 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $97 | 0% | $97 |
Medium |
| Root Canal - Anterior Tooth | $1,062 | 0% | $1,062 |
Medium |
| Root Canal - Bicuspid Tooth | $1,541 | 0% | $1,541 |
Medium |
| Root Canal - Molar | $1,455 | 0% | $1,455 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $66 | 0% | $66 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
Medium |
| X-Ray - Complete Intraoral Series | $218 | 0% | $218 |
Medium |
| X-Ray - Four Images, Bitewings | $78 | 0% | $78 |
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 | $161 | 0% | $161 |
Medium |
