| Dental Cleaning - Adult | $126 | 0% | $126 | 
Medium |
| Dental Cleaning - Child | $101 | 0% | $101 |
Medium |
| Dental Exam - Comprehensive | $116 | 0% | $116 |
Medium |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $293 | 0% | $293 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $268 | 0% | $268 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $226 | 0% | $226 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $246 | 0% | $246 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $300 | 0% | $300 |
Medium |
| Flouride - Topical Varnish Application | $53 | 0% | $53 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $106 | 0% | $106 |
Medium |
| Root Canal - Anterior Tooth | $1,050 | 0% | $1,050 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $78 | 0% | $78 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $209 | 0% | $209 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $39 | 0% | $39 |
Medium |
| X-Ray - Complete Intraoral Series | $177 | 0% | $177 |
Medium |
| X-Ray - Four Images, Bitewings | $95 | 0% | $95 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
Medium |
| X-Ray - Two Images, Bitewings | $70 | 0% | $70 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $177 | 0% | $177 |
Medium |
