| Dental Cleaning - Adult | $91 | 0% | $91 | 
Medium |
| Dental Cleaning - Child | $67 | 0% | $67 |
Medium |
| Dental Exam - Comprehensive | $80 | 0% | $80 |
Medium |
| Dental Exam - Periodic, Established Patient | $40 | 0% | $40 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $142 | 0% | $142 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $230 | 0% | $230 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $191 | 0% | $191 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $145 | 0% | $145 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $143 | 0% | $143 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $275 | 0% | $275 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $181 | 0% | $181 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $221 | 0% | $221 |
Medium |
| Flouride - Topical Varnish Application | $45 | 0% | $45 |
Medium |
| Maintenance Therapy - Periodontal | $132 | 0% | $132 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $68 | 0% | $68 |
Medium |
| Root Canal - Anterior Tooth | $697 | 0% | $697 |
Medium |
| Root Canal - Bicuspid Tooth | $924 | 0% | $924 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $48 | 0% | $48 |
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 | $21 | 0% | $21 |
Medium |
| X-Ray - Complete Intraoral Series | $159 | 0% | $159 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $30 | 0% | $30 |
Medium |
| X-Ray - Two Images, Bitewings | $43 | 0% | $43 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $118 | 0% | $118 |
Medium |
