| Dental Cleaning - Adult | $106 | 0% | $106 | 
Medium |
| Dental Cleaning - Child | $120 | 0% | $120 |
Medium |
| Dental Exam - Comprehensive | $109 | 0% | $109 |
Medium |
| Dental Exam - Periodic, Established Patient | $48 | 0% | $48 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $177 | 0% | $177 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $299 | 0% | $299 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $245 | 0% | $245 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $164 | 0% | $164 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $177 | 0% | $177 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $391 | 0% | $391 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $202 | 0% | $202 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $313 | 0% | $313 |
Medium |
| Flouride - Topical Varnish Application | $37 | 0% | $37 |
Medium |
| Fluoride - Topical Application | $69 | 0% | $69 |
Medium |
| Maintenance Therapy - Periodontal | $189 | 0% | $189 |
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 | $86 | 0% | $86 |
Medium |
| Root Canal - Anterior Tooth | $821 | 0% | $821 |
Medium |
| Root Canal - Bicuspid Tooth | $1,247 | 0% | $1,247 |
Medium |
| Root Canal - Molar | $1,481 | 0% | $1,481 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $55 | 0% | $55 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $172 | 0% | $172 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
Medium |
| X-Ray - Complete Intraoral Series | $218 | 0% | $218 |
Medium |
| X-Ray - Four Images, Bitewings | $95 | 0% | $95 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
Medium |
| X-Ray - Two Images, Bitewings | $49 | 0% | $49 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $126 | 0% | $126 |
Medium |
