| Dental Cleaning - Adult | $127 | 0% | $127 | 
Medium |
| Dental Cleaning - Child | $68 | 0% | $68 |
Medium |
| Dental Exam - Comprehensive | $112 | 0% | $112 |
Medium |
| Dental Exam - Periodic, Established Patient | $44 | 0% | $44 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $176 | 0% | $176 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $313 | 0% | $313 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $184 | 0% | $184 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $200 | 0% | $200 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $169 | 0% | $169 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $411 | 0% | $411 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $243 | 0% | $243 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $243 | 0% | $243 |
Medium |
| Flouride - Topical Varnish Application | $51 | 0% | $51 |
Medium |
| Fluoride - Topical Application | $34 | 0% | $34 |
Medium |
| Maintenance Therapy - Periodontal | $186 | 0% | $186 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $334 | 0% | $334 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $81 | 0% | $81 |
Medium |
| Root Canal - Anterior Tooth | $1,098 | 0% | $1,098 |
Medium |
| Root Canal - Bicuspid Tooth | $1,274 | 0% | $1,274 |
Medium |
| Root Canal - Molar | $1,511 | 0% | $1,511 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $51 | 0% | $51 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $219 | 0% | $219 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
Medium |
| X-Ray - Complete Intraoral Series | $179 | 0% | $179 |
Medium |
| X-Ray - Four Images, Bitewings | $63 | 0% | $63 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
Medium |
| X-Ray - Two Images, Bitewings | $48 | 0% | $48 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $158 | 0% | $158 |
Medium |
