| Dental Cleaning - Adult | $118 | 0% | $118 | 
Medium |
| Dental Cleaning - Child | $85 | 0% | $85 |
Medium |
| Dental Exam - Comprehensive | $147 | 0% | $147 |
Medium |
| Dental Exam - Periodic, Established Patient | $59 | 0% | $59 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $210 | 0% | $210 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $315 | 0% | $315 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $252 | 0% | $252 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $231 | 0% | $231 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $244 | 0% | $244 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $389 | 0% | $389 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $289 | 0% | $289 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $315 | 0% | $315 |
Medium |
| Flouride - Topical Varnish Application | $56 | 0% | $56 |
Medium |
| Maintenance Therapy - Periodontal | $163 | 0% | $163 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $106 | 0% | $106 |
Medium |
| Root Canal - Bicuspid Tooth | $1,155 | 0% | $1,155 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $236 | 0% | $236 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
Medium |
| X-Ray - Complete Intraoral Series | $232 | 0% | $232 |
Medium |
| X-Ray - Four Images, Bitewings | $86 | 0% | $86 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
Medium |
| X-Ray - Two Images, Bitewings | $82 | 0% | $82 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $147 | 0% | $147 |
Medium |
