| Dental Cleaning - Adult | $112 | 0% | $112 | 
Medium |
| Dental Cleaning - Child | $93 | 0% | $93 |
Medium |
| Dental Exam - Comprehensive | $103 | 0% | $103 |
Medium |
| Dental Exam - Periodic, Established Patient | $57 | 0% | $57 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $205 | 0% | $205 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $349 | 0% | $349 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $279 | 0% | $279 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $219 | 0% | $219 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $215 | 0% | $215 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $365 | 0% | $365 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $242 | 0% | $242 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $286 | 0% | $286 |
Medium |
| Flouride - Topical Varnish Application | $48 | 0% | $48 |
Medium |
| Maintenance Therapy - Periodontal | $179 | 0% | $179 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $303 | 0% | $303 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $98 | 0% | $98 |
Medium |
| Root Canal - Anterior Tooth | $2,048 | 0% | $2,048 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
Medium |
| X-Ray - Complete Intraoral Series | $177 | 0% | $177 |
Medium |
| X-Ray - Four Images, Bitewings | $82 | 0% | $82 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $53 | 0% | $53 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $139 | 0% | $139 |
Medium |
