| Dental Cleaning - Adult | $137 | 0% | $137 | 
Medium |
| Dental Cleaning - Child | $97 | 0% | $97 |
Medium |
| Dental Exam - Comprehensive | $105 | 0% | $105 |
Medium |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $260 | 0% | $260 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $357 | 0% | $357 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $281 | 0% | $281 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $218 | 0% | $218 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $260 | 0% | $260 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $358 | 0% | $358 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $239 | 0% | $239 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $281 | 0% | $281 |
Medium |
| Fluoride - Topical Application | $63 | 0% | $63 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $310 | 0% | $310 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $164 | 0% | $164 |
Medium |
| Root Canal - Anterior Tooth | $1,024 | 0% | $1,024 |
Medium |
| Root Canal - Bicuspid Tooth | $2,468 | 0% | $2,468 |
Medium |
| Root Canal - Molar | $1,449 | 0% | $1,449 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $83 | 0% | $83 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $263 | 0% | $263 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
Medium |
| X-Ray - Complete Intraoral Series | $195 | 0% | $195 |
Medium |
| X-Ray - Four Images, Bitewings | $90 | 0% | $90 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $41 | 0% | $41 |
Medium |
| X-Ray - Two Images, Bitewings | $68 | 0% | $68 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $200 | 0% | $200 |
Medium |
