| Dental Cleaning - Adult | $103 | 0% | $103 | 
Medium |
| Dental Cleaning - Child | $80 | 0% | $80 |
Medium |
| Dental Exam - Comprehensive | $85 | 0% | $85 |
Medium |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $221 | 0% | $221 |
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 | $207 | 0% | $207 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $195 | 0% | $195 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $334 | 0% | $334 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $215 | 0% | $215 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $261 | 0% | $261 |
Medium |
| Flouride - Topical Varnish Application | $36 | 0% | $36 |
Medium |
| Fluoride - Topical Application | $68 | 0% | $68 |
Medium |
| Maintenance Therapy - Periodontal | $201 | 0% | $201 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $87 | 0% | $87 |
Medium |
| Root Canal - Anterior Tooth | $942 | 0% | $942 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $54 | 0% | $54 |
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 | $44 | 0% | $44 |
Medium |
| X-Ray - Complete Intraoral Series | $142 | 0% | $142 |
Medium |
| X-Ray - Four Images, Bitewings | $69 | 0% | $69 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
Medium |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $204 | 0% | $204 |
Medium |
