| Dental Cleaning - Adult | $91 | 0% | $91 | 
Medium |
| Dental Cleaning - Child | $68 | 0% | $68 |
Medium |
| Dental Exam - Comprehensive | $79 | 0% | $79 |
Medium |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $142 | 0% | $142 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $284 | 0% | $284 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $231 | 0% | $231 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $158 | 0% | $158 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $179 | 0% | $179 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $284 | 0% | $284 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $200 | 0% | $200 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $231 | 0% | $231 |
Medium |
| Flouride - Topical Varnish Application | $37 | 0% | $37 |
Medium |
| Fluoride - Topical Application | $32 | 0% | $32 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $84 | 0% | $84 |
Medium |
| Root Canal - Bicuspid Tooth | $835 | 0% | $835 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $53 | 0% | $53 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $173 | 0% | $173 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
Medium |
| X-Ray - Complete Intraoral Series | $142 | 0% | $142 |
Medium |
| X-Ray - Four Images, Bitewings | $74 | 0% | $74 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
Medium |
| X-Ray - Two Images, Bitewings | $47 | 0% | $47 |
Medium |
