| Dental Cleaning - Adult | $110 | 0% | $110 | 
Medium |
| Dental Cleaning - Child | $88 | 0% | $88 |
Medium |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $185 | 0% | $185 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $318 | 0% | $318 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $235 | 0% | $235 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $208 | 0% | $208 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $196 | 0% | $196 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $370 | 0% | $370 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $269 | 0% | $269 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $242 | 0% | $242 |
Medium |
| Flouride - Topical Varnish Application | $58 | 0% | $58 |
Medium |
| Maintenance Therapy - Periodontal | $193 | 0% | $193 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $315 | 0% | $315 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | 0% | $101 |
Medium |
| Root Canal - Anterior Tooth | $1,029 | 0% | $1,029 |
Medium |
| Root Canal - Bicuspid Tooth | $1,150 | 0% | $1,150 |
Medium |
| Root Canal - Molar | $1,418 | 0% | $1,418 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $70 | 0% | $70 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $191 | 0% | $191 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
Medium |
| X-Ray - Complete Intraoral Series | $197 | 0% | $197 |
Medium |
| X-Ray - Four Images, Bitewings | $107 | 0% | $107 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
Medium |
| X-Ray - Two Images, Bitewings | $74 | 0% | $74 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $187 | 0% | $187 |
Medium |
