| 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 | $290 | 0% | $290 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $242 | 0% | $242 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $208 | 0% | $208 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $204 | 0% | $204 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $292 | 0% | $292 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $251 | 0% | $251 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
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 | $345 | 0% | $345 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $93 | 0% | $93 |
Medium |
| Root Canal - Bicuspid Tooth | $1,313 | 0% | $1,313 |
Medium |
| Root Canal - Molar | $1,758 | 0% | $1,758 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $67 | 0% | $67 |
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 | $47 | 0% | $47 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $159 | 0% | $159 |
Medium |
