| Dental Cleaning - Adult | $116 | 0% | $116 | 
Medium |
| Dental Cleaning - Child | $92 | 0% | $92 |
Medium |
| Dental Exam - Comprehensive | $102 | 0% | $102 |
Medium |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $232 | 0% | $232 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $358 | 0% | $358 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $288 | 0% | $288 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $259 | 0% | $259 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $232 | 0% | $232 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $358 | 0% | $358 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $259 | 0% | $259 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $288 | 0% | $288 |
Medium |
| Flouride - Topical Varnish Application | $54 | 0% | $54 |
Medium |
| Maintenance Therapy - Periodontal | $169 | 0% | $169 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $333 | 0% | $333 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $110 | 0% | $110 |
Medium |
| Root Canal - Anterior Tooth | $942 | 0% | $942 |
Medium |
| Root Canal - Bicuspid Tooth | $1,068 | 0% | $1,068 |
Medium |
| Root Canal - Molar | $1,288 | 0% | $1,288 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $70 | 0% | $70 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
Medium |
| X-Ray - Complete Intraoral Series | $161 | 0% | $161 |
Medium |
| X-Ray - Four Images, Bitewings | $83 | 0% | $83 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
Medium |
| X-Ray - Two Images, Bitewings | $60 | 0% | $60 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $140 | 0% | $140 |
Medium |
