| Dental Cleaning - Adult | $109 | 0% | $109 | 
Medium |
| Dental Cleaning - Child | $96 | 0% | $96 |
Medium |
| Dental Exam - Comprehensive | $104 | 0% | $104 |
Medium |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | 0% | $208 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $324 | 0% | $324 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | 0% | $263 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $194 | 0% | $194 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $211 | 0% | $211 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $391 | 0% | $391 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | 0% | $271 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $269 | 0% | $269 |
Medium |
| Flouride - Topical Varnish Application | $49 | 0% | $49 |
Medium |
| Fluoride - Topical Application | $45 | 0% | $45 |
Medium |
| Maintenance Therapy - Periodontal | $212 | 0% | $212 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $395 | 0% | $395 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
Medium |
| Root Canal - Anterior Tooth | $889 | 0% | $889 |
Medium |
| Root Canal - Bicuspid Tooth | $1,026 | 0% | $1,026 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $62 | 0% | $62 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $260 | 0% | $260 |
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 | $76 | 0% | $76 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | 0% | $36 |
Medium |
| X-Ray - Two Images, Bitewings | $61 | 0% | $61 |
Medium |
