| Dental Cleaning - Adult | $86 | 0% | $86 | 
Medium |
| Dental Cleaning - Child | $69 | 0% | $69 |
Medium |
| Dental Exam - Periodic, Established Patient | $42 | 0% | $42 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $123 | 0% | $123 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $158 | 0% | $158 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $137 | 0% | $137 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $142 | 0% | $142 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $158 | 0% | $158 |
Medium |
| Fluoride - Topical Application | $32 | 0% | $32 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $221 | 0% | $221 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $72 | 0% | $72 |
Medium |
| Root Canal - Anterior Tooth | $761 | 0% | $761 |
Medium |
| Root Canal - Bicuspid Tooth | $798 | 0% | $798 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $147 | 0% | $147 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $21 | 0% | $21 |
Medium |
| X-Ray - Four Images, Bitewings | $58 | 0% | $58 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $26 | 0% | $26 |
Medium |
| X-Ray - Two Images, Bitewings | $42 | 0% | $42 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $107 | 0% | $107 |
Medium |
