| Dental Cleaning - Adult | $92 | 0% | $92 | 
Medium |
| Dental Cleaning - Child | $74 | 0% | $74 |
Medium |
| Dental Exam - Comprehensive | $85 | 0% | $85 |
Medium |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $173 | 0% | $173 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $257 | 0% | $257 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $205 | 0% | $205 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $212 | 0% | $212 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $173 | 0% | $173 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $257 | 0% | $257 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | 0% | $271 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $205 | 0% | $205 |
Medium |
| Fluoride - Topical Application | $46 | 0% | $46 |
Medium |
| Maintenance Therapy - Periodontal | $212 | 0% | $212 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $236 | 0% | $236 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $79 | 0% | $79 |
Medium |
| Root Canal - Anterior Tooth | $1,079 | 0% | $1,079 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $53 | 0% | $53 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $168 | 0% | $168 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
Medium |
| X-Ray - Complete Intraoral Series | $144 | 0% | $144 |
Medium |
| X-Ray - Four Images, Bitewings | $66 | 0% | $66 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
Medium |
| X-Ray - Two Images, Bitewings | $61 | 0% | $61 |
Medium |
