| Dental Cleaning - Adult | $116 | 0% | $116 | 
Medium |
| Dental Cleaning - Child | $86 | 0% | $86 |
Medium |
| Dental Exam - Comprehensive | $102 | 0% | $102 |
Medium |
| Dental Exam - Periodic, Established Patient | $56 | 0% | $56 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $228 | 0% | $228 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $377 | 0% | $377 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $298 | 0% | $298 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $221 | 0% | $221 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $228 | 0% | $228 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $377 | 0% | $377 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $261 | 0% | $261 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $298 | 0% | $298 |
Medium |
| Flouride - Topical Varnish Application | $56 | 0% | $56 |
Medium |
| Maintenance Therapy - Periodontal | $166 | 0% | $166 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $316 | 0% | $316 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $97 | 0% | $97 |
Medium |
| Root Canal - Bicuspid Tooth | $1,005 | 0% | $1,005 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $70 | 0% | $70 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $222 | 0% | $222 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | 0% | $38 |
Medium |
| X-Ray - Complete Intraoral Series | $170 | 0% | $170 |
Medium |
| X-Ray - Four Images, Bitewings | $83 | 0% | $83 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
Medium |
| X-Ray - Two Images, Bitewings | $59 | 0% | $59 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $140 | 0% | $140 |
Medium |
