| Dental Cleaning - Adult | $101 | 0% | $101 | 
Medium |
| Dental Cleaning - Child | $80 | 0% | $80 |
Medium |
| Dental Exam - Comprehensive | $95 | 0% | $95 |
Medium |
| Dental Exam - Periodic, Established Patient | $54 | 0% | $54 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $192 | 0% | $192 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $234 | 0% | $234 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $190 | 0% | $190 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $173 | 0% | $173 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $213 | 0% | $213 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $308 | 0% | $308 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $213 | 0% | $213 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $268 | 0% | $268 |
Medium |
| Flouride - Topical Varnish Application | $38 | 0% | $38 |
Medium |
| Fluoride - Topical Application | $40 | 0% | $40 |
Medium |
| Maintenance Therapy - Periodontal | $169 | 0% | $169 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $273 | 0% | $273 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $81 | 0% | $81 |
Medium |
| Root Canal - Anterior Tooth | $769 | 0% | $769 |
Medium |
| Root Canal - Bicuspid Tooth | $1,541 | 0% | $1,541 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | 0% | $59 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | 0% | $184 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
Medium |
| X-Ray - Complete Intraoral Series | $138 | 0% | $138 |
Medium |
| X-Ray - Four Images, Bitewings | $80 | 0% | $80 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $29 | 0% | $29 |
Medium |
| X-Ray - Two Images, Bitewings | $47 | 0% | $47 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $152 | 0% | $152 |
Medium |
