| Dental Cleaning - Adult | $110 | 0% | $110 | 
Medium |
| Dental Cleaning - Child | $88 | 0% | $88 |
Medium |
| Dental Exam - Comprehensive | $102 | 0% | $102 |
Medium |
| Dental Exam - Periodic, Established Patient | $59 | 0% | $59 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $205 | 0% | $205 |
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 | $205 | 0% | $205 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $355 | 0% | $355 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $237 | 0% | $237 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $273 | 0% | $273 |
Medium |
| Fluoride - Topical Application | $46 | 0% | $46 |
Medium |
| Maintenance Therapy - Periodontal | $173 | 0% | $173 |
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 | $92 | 0% | $92 |
Medium |
| Root Canal - Anterior Tooth | $886 | 0% | $886 |
Medium |
| Root Canal - Bicuspid Tooth | $1,050 | 0% | $1,050 |
Medium |
| Root Canal - Molar | $1,857 | 0% | $1,857 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $65 | 0% | $65 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $181 | 0% | $181 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
Medium |
| X-Ray - Complete Intraoral Series | $152 | 0% | $152 |
Medium |
| X-Ray - Four Images, Bitewings | $75 | 0% | $75 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $54 | 0% | $54 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $160 | 0% | $160 |
Medium |
