| Dental Cleaning - Adult | $114 | 0% | $114 | 
Medium |
| Dental Cleaning - Child | $91 | 0% | $91 |
Medium |
| Dental Exam - Comprehensive | $106 | 0% | $106 |
Medium |
| Dental Exam - Periodic, Established Patient | $61 | 0% | $61 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $213 | 0% | $213 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $355 | 0% | $355 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $273 | 0% | $273 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $180 | 0% | $180 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $213 | 0% | $213 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $395 | 0% | $395 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $247 | 0% | $247 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $284 | 0% | $284 |
Medium |
| Flouride - Topical Varnish Application | $49 | 0% | $49 |
Medium |
| Fluoride - Topical Application | $46 | 0% | $46 |
Medium |
| Maintenance Therapy - Periodontal | $181 | 0% | $181 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $314 | 0% | $314 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $97 | 0% | $97 |
Medium |
| Root Canal - Anterior Tooth | $886 | 0% | $886 |
Medium |
| Root Canal - Bicuspid Tooth | $1,071 | 0% | $1,071 |
Medium |
| Root Canal - Molar | $1,352 | 0% | $1,352 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $65 | 0% | $65 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $190 | 0% | $190 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | 0% | $30 |
Medium |
| X-Ray - Complete Intraoral Series | $159 | 0% | $159 |
Medium |
| X-Ray - Four Images, Bitewings | $78 | 0% | $78 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $56 | 0% | $56 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $160 | 0% | $160 |
Medium |
