| Dental Cleaning - Adult | $122 | 0% | $122 | 
Medium |
| Dental Cleaning - Child | $97 | 0% | $97 |
Medium |
| Dental Exam - Comprehensive | $111 | 0% | $111 |
Medium |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $230 | 0% | $230 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $345 | 0% | $345 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $282 | 0% | $282 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $212 | 0% | $212 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $230 | 0% | $230 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $345 | 0% | $345 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $254 | 0% | $254 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $282 | 0% | $282 |
Medium |
| Flouride - Topical Varnish Application | $55 | 0% | $55 |
Medium |
| Maintenance Therapy - Periodontal | $160 | 0% | $160 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $93 | 0% | $93 |
Medium |
| Root Canal - Molar | $1,322 | 0% | $1,322 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $76 | 0% | $76 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
Medium |
| X-Ray - Four Images, Bitewings | $83 | 0% | $83 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
Medium |
| X-Ray - Two Images, Bitewings | $62 | 0% | $62 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $164 | 0% | $164 |
Medium |
