| Dental Cleaning - Adult | $113 | 0% | $113 | 
Medium |
| Dental Cleaning - Child | $168 | 0% | $168 |
Medium |
| Dental Exam - Comprehensive | $119 | 0% | $119 |
Medium |
| Dental Exam - Periodic, Established Patient | $62 | 0% | $62 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $186 | 0% | $186 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $276 | 0% | $276 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $233 | 0% | $233 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $207 | 0% | $207 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $222 | 0% | $222 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $695 | 0% | $695 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $250 | 0% | $250 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $282 | 0% | $282 |
Medium |
| Flouride - Topical Varnish Application | $47 | 0% | $47 |
Medium |
| Maintenance Therapy - Periodontal | $176 | 0% | $176 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $317 | 0% | $317 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $93 | 0% | $93 |
Medium |
| Root Canal - Bicuspid Tooth | $1,103 | 0% | $1,103 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $234 | 0% | $234 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | 0% | $30 |
Medium |
| X-Ray - Complete Intraoral Series | $166 | 0% | $166 |
Medium |
| X-Ray - Four Images, Bitewings | $83 | 0% | $83 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $59 | 0% | $59 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $145 | 0% | $145 |
Medium |
