| Dental Cleaning - Adult | $96 | 0% | $96 | 
Medium |
| Dental Cleaning - Child | $71 | 0% | $71 |
Medium |
| Dental Exam - Comprehensive | $83 | 0% | $83 |
Medium |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $149 | 0% | $149 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $312 | 0% | $312 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $243 | 0% | $243 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $158 | 0% | $158 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $187 | 0% | $187 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $297 | 0% | $297 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $209 | 0% | $209 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $243 | 0% | $243 |
Medium |
| Flouride - Topical Varnish Application | $39 | 0% | $39 |
Medium |
| Fluoride - Topical Application | $32 | 0% | $32 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $252 | 0% | $252 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $84 | 0% | $84 |
Medium |
| Root Canal - Anterior Tooth | $772 | 0% | $772 |
Medium |
| Root Canal - Bicuspid Tooth | $835 | 0% | $835 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $56 | 0% | $56 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $182 | 0% | $182 |
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 | $69 | 0% | $69 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
Medium |
| X-Ray - Two Images, Bitewings | $49 | 0% | $49 |
Medium |
