| Dental Cleaning - Adult | $138 | 0% | $138 | 
Medium |
| Dental Cleaning - Child | $96 | 0% | $96 |
Medium |
| Dental Exam - Comprehensive | $153 | 0% | $153 |
Medium |
| Dental Exam - Periodic, Established Patient | $64 | 0% | $64 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $230 | 0% | $230 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $383 | 0% | $383 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $305 | 0% | $305 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $272 | 0% | $272 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $284 | 0% | $284 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $491 | 0% | $491 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $372 | 0% | $372 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $402 | 0% | $402 |
Medium |
| Flouride - Topical Varnish Application | $62 | 0% | $62 |
Medium |
| Fluoride - Topical Application | $62 | 0% | $62 |
Medium |
| Maintenance Therapy - Periodontal | $166 | 0% | $166 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $348 | 0% | $348 |
Medium |
| Root Canal - Anterior Tooth | $1,092 | 0% | $1,092 |
Medium |
| Root Canal - Bicuspid Tooth | $1,229 | 0% | $1,229 |
Medium |
| Root Canal - Molar | $1,489 | 0% | $1,489 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $86 | 0% | $86 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $266 | 0% | $266 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $44 | 0% | $44 |
Medium |
| X-Ray - Complete Intraoral Series | $208 | 0% | $208 |
Medium |
| X-Ray - Four Images, Bitewings | $105 | 0% | $105 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $50 | 0% | $50 |
Medium |
| X-Ray - Two Images, Bitewings | $75 | 0% | $75 |
Medium |
