| Dental Cleaning - Adult | $95 | 0% | $95 | 
Medium |
| Dental Cleaning - Child | $70 | 0% | $70 |
Medium |
| Dental Exam - Comprehensive | $77 | 0% | $77 |
Medium |
| Dental Exam - Periodic, Established Patient | $42 | 0% | $42 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $126 | 0% | $126 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $189 | 0% | $189 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $153 | 0% | $153 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $140 | 0% | $140 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $153 | 0% | $153 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $282 | 0% | $282 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $171 | 0% | $171 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $217 | 0% | $217 |
Medium |
| Flouride - Topical Varnish Application | $36 | 0% | $36 |
Medium |
| Fluoride - Topical Application | $36 | 0% | $36 |
Medium |
| Maintenance Therapy - Periodontal | $254 | 0% | $254 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $231 | 0% | $231 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $74 | 0% | $74 |
Medium |
| Root Canal - Anterior Tooth | $1,103 | 0% | $1,103 |
Medium |
| Root Canal - Bicuspid Tooth | $840 | 0% | $840 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $48 | 0% | $48 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $307 | 0% | $307 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $23 | 0% | $23 |
Medium |
| X-Ray - Complete Intraoral Series | $126 | 0% | $126 |
Medium |
| X-Ray - Four Images, Bitewings | $63 | 0% | $63 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $29 | 0% | $29 |
Medium |
| X-Ray - Two Images, Bitewings | $43 | 0% | $43 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $116 | 0% | $116 |
Medium |
