| Dental Cleaning - Adult | $189 | 0% | $189 | 
Medium |
| Dental Cleaning - Child | $168 | 0% | $168 |
Medium |
| Dental Exam - Comprehensive | $130 | 0% | $130 |
Medium |
| Dental Exam - Periodic, Established Patient | $82 | 0% | $82 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $370 | 0% | $370 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $300 | 0% | $300 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $321 | 0% | $321 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $563 | 0% | $563 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $390 | 0% | $390 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $439 | 0% | $439 |
Medium |
| Maintenance Therapy - Periodontal | $216 | 0% | $216 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $506 | 0% | $506 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $130 | 0% | $130 |
Medium |
| Root Canal - Bicuspid Tooth | $1,518 | 0% | $1,518 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $116 | 0% | $116 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $319 | 0% | $319 |
Medium |
| X-Ray - Complete Intraoral Series | $237 | 0% | $237 |
Medium |
| X-Ray - Four Images, Bitewings | $130 | 0% | $130 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $57 | 0% | $57 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $242 | 0% | $242 |
Medium |
