| Dental Cleaning - Adult | $118 | 0% | $118 | 
Medium |
| Dental Cleaning - Child | $183 | 0% | $183 |
Medium |
| Dental Exam - Periodic, Established Patient | $68 | 0% | $68 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $378 | 0% | $378 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $377 | 0% | $377 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $299 | 0% | $299 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $232 | 0% | $232 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $236 | 0% | $236 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $368 | 0% | $368 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $287 | 0% | $287 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $299 | 0% | $299 |
Medium |
| Flouride - Topical Varnish Application | $56 | 0% | $56 |
Medium |
| Maintenance Therapy - Periodontal | $172 | 0% | $172 |
Medium |
| Root Canal - Bicuspid Tooth | $1,168 | 0% | $1,168 |
Medium |
| Root Canal - Molar | $1,489 | 0% | $1,489 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $265 | 0% | $265 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | 0% | $33 |
Medium |
| X-Ray - Complete Intraoral Series | $183 | 0% | $183 |
Medium |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
Medium |
| X-Ray - Two Images, Bitewings | $61 | 0% | $61 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $305 | 0% | $305 |
Medium |
