| Dental Cleaning - Adult | $123 | 0% | $123 | 
Medium |
| Dental Cleaning - Child | $80 | 0% | $80 |
Medium |
| Dental Exam - Comprehensive | $85 | 0% | $85 |
Medium |
| Dental Exam - Periodic, Established Patient | $51 | 0% | $51 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $214 | 0% | $214 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $334 | 0% | $334 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $261 | 0% | $261 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $196 | 0% | $196 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $214 | 0% | $214 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $370 | 0% | $370 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $269 | 0% | $269 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $299 | 0% | $299 |
Medium |
| Flouride - Topical Varnish Application | $36 | 0% | $36 |
Medium |
| Fluoride - Topical Application | $71 | 0% | $71 |
Medium |
| Maintenance Therapy - Periodontal | $195 | 0% | $195 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $257 | 0% | $257 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $87 | 0% | $87 |
Medium |
| Root Canal - Anterior Tooth | $814 | 0% | $814 |
Medium |
| Root Canal - Bicuspid Tooth | $1,180 | 0% | $1,180 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | 0% | $74 |
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 | $41 | 0% | $41 |
Medium |
| X-Ray - Complete Intraoral Series | $171 | 0% | $171 |
Medium |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $48 | 0% | $48 |
Medium |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $193 | 0% | $193 |
Medium |
