| Dental Cleaning - Adult | $116 | 0% | $116 | 
Medium |
| Dental Cleaning - Child | $85 | 0% | $85 |
Medium |
| Dental Exam - Comprehensive | $145 | 0% | $145 |
Medium |
| Dental Exam - Periodic, Established Patient | $59 | 0% | $59 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $196 | 0% | $196 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $309 | 0% | $309 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $247 | 0% | $247 |
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 | $277 | 0% | $277 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $371 | 0% | $371 |
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 | $104 | 0% | $104 |
Medium |
| Root Canal - Bicuspid Tooth | $1,155 | 0% | $1,155 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $234 | 0% | $234 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $23 | 0% | $23 |
Medium |
| X-Ray - Complete Intraoral Series | $231 | 0% | $231 |
Medium |
| X-Ray - Four Images, Bitewings | $86 | 0% | $86 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
Medium |
| X-Ray - Two Images, Bitewings | $55 | 0% | $55 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $145 | 0% | $145 |
Medium |
