| Dental Cleaning - Adult | $120 | 0% | $120 | 
Medium |
| Dental Cleaning - Child | $88 | 0% | $88 |
Medium |
| Dental Exam - Comprehensive | $103 | 0% | $103 |
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 | $331 | 0% | $331 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $274 | 0% | $274 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $182 | 0% | $182 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $209 | 0% | $209 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $356 | 0% | $356 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $246 | 0% | $246 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $277 | 0% | $277 |
Medium |
| Flouride - Topical Varnish Application | $48 | 0% | $48 |
Medium |
| Fluoride - Topical Application | $48 | 0% | $48 |
Medium |
| Maintenance Therapy - Periodontal | $182 | 0% | $182 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $313 | 0% | $313 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $111 | 0% | $111 |
Medium |
| Root Canal - Bicuspid Tooth | $2,221 | 0% | $2,221 |
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 | $27 | 0% | $27 |
Medium |
| X-Ray - Complete Intraoral Series | $234 | 0% | $234 |
Medium |
| X-Ray - Four Images, Bitewings | $82 | 0% | $82 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $44 | 0% | $44 |
Medium |
| X-Ray - Two Images, Bitewings | $57 | 0% | $57 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $152 | 0% | $152 |
Medium |
