| Dental Cleaning - Adult | $110 | 0% | $110 | 
Medium |
| Dental Cleaning - Child | $89 | 0% | $89 |
Medium |
| Dental Exam - Comprehensive | $104 | 0% | $104 |
Medium |
| Dental Exam - Periodic, Established Patient | $57 | 0% | $57 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $201 | 0% | $201 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $328 | 0% | $328 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $258 | 0% | $258 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $179 | 0% | $179 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $201 | 0% | $201 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $336 | 0% | $336 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $225 | 0% | $225 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
Medium |
| Fluoride - Topical Application | $47 | 0% | $47 |
Medium |
| Maintenance Therapy - Periodontal | $154 | 0% | $154 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $281 | 0% | $281 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | 0% | $92 |
Medium |
| Root Canal - Anterior Tooth | $1,129 | 0% | $1,129 |
Medium |
| Root Canal - Bicuspid Tooth | $1,113 | 0% | $1,113 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $221 | 0% | $221 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
Medium |
| X-Ray - Complete Intraoral Series | $152 | 0% | $152 |
Medium |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
Medium |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
Medium |
