| Dental Cleaning - Adult | $140 | 0% | $140 | 
Medium |
| Dental Cleaning - Child | $85 | 0% | $85 |
Medium |
| Dental Exam - Comprehensive | $128 | 0% | $128 |
Medium |
| Dental Exam - Periodic, Established Patient | $43 | 0% | $43 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | 0% | $189 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $268 | 0% | $268 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | 0% | $263 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $189 | 0% | $189 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $378 | 0% | $378 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $364 | 0% | $364 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $269 | 0% | $269 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $302 | 0% | $302 |
Medium |
| Flouride - Topical Varnish Application | $48 | 0% | $48 |
Medium |
| Maintenance Therapy - Periodontal | $279 | 0% | $279 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $500 | 0% | $500 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $140 | 0% | $140 |
Medium |
| Root Canal - Anterior Tooth | $1,987 | 0% | $1,987 |
Medium |
| Root Canal - Bicuspid Tooth | $1,147 | 0% | $1,147 |
Medium |
| Root Canal - Molar | $2,130 | 0% | $2,130 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $77 | 0% | $77 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $242 | 0% | $242 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | 0% | $30 |
Medium |
| X-Ray - Complete Intraoral Series | $196 | 0% | $196 |
Medium |
| X-Ray - Four Images, Bitewings | $95 | 0% | $95 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
Medium |
| X-Ray - Two Images, Bitewings | $80 | 0% | $80 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $156 | 0% | $156 |
Medium |
