| Dental Cleaning - Adult | $109 | 0% | $109 | 
Medium |
| Dental Cleaning - Child | $84 | 0% | $84 |
Medium |
| Dental Exam - Comprehensive | $76 | 0% | $76 |
Medium |
| Dental Exam - Periodic, Established Patient | $46 | 0% | $46 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $187 | 0% | $187 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $289 | 0% | $289 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $251 | 0% | $251 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $292 | 0% | $292 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $194 | 0% | $194 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $303 | 0% | $303 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $261 | 0% | $261 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $281 | 0% | $281 |
Medium |
| Flouride - Topical Varnish Application | $53 | 0% | $53 |
Medium |
| Maintenance Therapy - Periodontal | $151 | 0% | $151 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $356 | 0% | $356 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $98 | 0% | $98 |
Medium |
| Root Canal - Anterior Tooth | $1,092 | 0% | $1,092 |
Medium |
| Root Canal - Bicuspid Tooth | $1,285 | 0% | $1,285 |
Medium |
| Root Canal - Molar | $1,654 | 0% | $1,654 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $79 | 0% | $79 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $23 | 0% | $23 |
Medium |
| X-Ray - Complete Intraoral Series | $147 | 0% | $147 |
Medium |
| X-Ray - Four Images, Bitewings | $77 | 0% | $77 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $147 | 0% | $147 |
Medium |
