| Dental Cleaning - Adult | $168 | 0% | $168 | 
Medium |
| Dental Cleaning - Child | $95 | 0% | $95 |
Medium |
| Dental Exam - Periodic, Established Patient | $95 | 0% | $95 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $273 | 0% | $273 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $200 | 0% | $200 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $168 | 0% | $168 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $147 | 0% | $147 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $347 | 0% | $347 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $515 | 0% | $515 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $357 | 0% | $357 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $431 | 0% | $431 |
Medium |
| Fluoride - Topical Application | $42 | 0% | $42 |
Medium |
| Maintenance Therapy - Periodontal | $284 | 0% | $284 |
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 | $118 | 0% | $118 |
Medium |
| Root Canal - Bicuspid Tooth | $1,890 | 0% | $1,890 |
Medium |
| Root Canal - Molar | $2,310 | 0% | $2,310 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $284 | 0% | $284 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $21 | 0% | $21 |
Medium |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
Medium |
