| Dental Cleaning - Adult | $102 | 0% | $102 | 
Medium |
| Dental Cleaning - Child | $76 | 0% | $76 |
Medium |
| Dental Exam - Comprehensive | $86 | 0% | $86 |
Medium |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $177 | 0% | $177 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $313 | 0% | $313 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $251 | 0% | $251 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $159 | 0% | $159 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $177 | 0% | $177 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $313 | 0% | $313 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $194 | 0% | $194 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $251 | 0% | $251 |
Medium |
| Flouride - Topical Varnish Application | $39 | 0% | $39 |
Medium |
| Fluoride - Topical Application | $39 | 0% | $39 |
Medium |
| Maintenance Therapy - Periodontal | $139 | 0% | $139 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $254 | 0% | $254 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $85 | 0% | $85 |
Medium |
| Root Canal - Anterior Tooth | $801 | 0% | $801 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $56 | 0% | $56 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $177 | 0% | $177 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $23 | 0% | $23 |
Medium |
| X-Ray - Complete Intraoral Series | $135 | 0% | $135 |
Medium |
| X-Ray - Four Images, Bitewings | $66 | 0% | $66 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $30 | 0% | $30 |
Medium |
| X-Ray - Two Images, Bitewings | $46 | 0% | $46 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $123 | 0% | $123 |
Medium |
