| Dental Cleaning - Adult | $164 | 0% | $164 | 
Medium |
| Dental Cleaning - Child | $116 | 0% | $116 |
Medium |
| Dental Exam - Comprehensive | $84 | 0% | $84 |
Medium |
| Dental Exam - Periodic, Established Patient | $42 | 0% | $42 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $200 | 0% | $200 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $315 | 0% | $315 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $257 | 0% | $257 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $168 | 0% | $168 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $200 | 0% | $200 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $315 | 0% | $315 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $210 | 0% | $210 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $257 | 0% | $257 |
Medium |
| Flouride - Topical Varnish Application | $37 | 0% | $37 |
Medium |
| Fluoride - Topical Application | $55 | 0% | $55 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $58 | 0% | $58 |
Medium |
| Root Canal - Bicuspid Tooth | $1,628 | 0% | $1,628 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $53 | 0% | $53 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $23 | 0% | $23 |
Medium |
| X-Ray - Complete Intraoral Series | $263 | 0% | $263 |
Medium |
| X-Ray - Four Images, Bitewings | $58 | 0% | $58 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $26 | 0% | $26 |
Medium |
| X-Ray - Two Images, Bitewings | $37 | 0% | $37 |
Medium |
