| Dental Cleaning - Adult | $111 | 0% | $111 | 
Medium |
| Dental Cleaning - Child | $88 | 0% | $88 |
Medium |
| Dental Exam - Comprehensive | $100 | 0% | $100 |
Medium |
| Dental Exam - Periodic, Established Patient | $57 | 0% | $57 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $201 | 0% | $201 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $323 | 0% | $323 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $291 | 0% | $291 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $179 | 0% | $179 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $207 | 0% | $207 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $365 | 0% | $365 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $221 | 0% | $221 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $291 | 0% | $291 |
Medium |
| Flouride - Topical Varnish Application | $45 | 0% | $45 |
Medium |
| Fluoride - Topical Application | $44 | 0% | $44 |
Medium |
| Maintenance Therapy - Periodontal | $160 | 0% | $160 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $308 | 0% | $308 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | 0% | $95 |
Medium |
| Root Canal - Anterior Tooth | $902 | 0% | $902 |
Medium |
| Root Canal - Bicuspid Tooth | $1,023 | 0% | $1,023 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $62 | 0% | $62 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $223 | 0% | $223 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
Medium |
| X-Ray - Complete Intraoral Series | $200 | 0% | $200 |
Medium |
| X-Ray - Four Images, Bitewings | $80 | 0% | $80 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | 0% | $36 |
Medium |
| X-Ray - Two Images, Bitewings | $53 | 0% | $53 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $149 | 0% | $149 |
Medium |
