| Dental Cleaning - Adult | $123 | 0% | $123 | 
Medium |
| Dental Cleaning - Child | $90 | 0% | $90 |
Medium |
| Dental Exam - Comprehensive | $96 | 0% | $96 |
Medium |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $209 | 0% | $209 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $235 | 0% | $235 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $253 | 0% | $253 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $192 | 0% | $192 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $213 | 0% | $213 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $563 | 0% | $563 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $246 | 0% | $246 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $258 | 0% | $258 |
Medium |
| Flouride - Topical Varnish Application | $48 | 0% | $48 |
Medium |
| Fluoride - Topical Application | $48 | 0% | $48 |
Medium |
| Maintenance Therapy - Periodontal | $185 | 0% | $185 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $322 | 0% | $322 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $112 | 0% | $112 |
Medium |
| Root Canal - Anterior Tooth | $1,339 | 0% | $1,339 |
Medium |
| Root Canal - Bicuspid Tooth | $1,896 | 0% | $1,896 |
Medium |
| Root Canal - Molar | $1,572 | 0% | $1,572 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $197 | 0% | $197 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
Medium |
| X-Ray - Complete Intraoral Series | $237 | 0% | $237 |
Medium |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $44 | 0% | $44 |
Medium |
| X-Ray - Two Images, Bitewings | $58 | 0% | $58 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $156 | 0% | $156 |
Medium |
