| Dental Cleaning - Adult | $96 | 0% | $96 | 
Medium |
| Dental Cleaning - Child | $82 | 0% | $82 |
Medium |
| Dental Exam - Comprehensive | $84 | 0% | $84 |
Medium |
| Dental Exam - Periodic, Established Patient | $59 | 0% | $59 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $152 | 0% | $152 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $263 | 0% | $263 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $206 | 0% | $206 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $152 | 0% | $152 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $152 | 0% | $152 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $263 | 0% | $263 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $206 | 0% | $206 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $206 | 0% | $206 |
Medium |
| Flouride - Topical Varnish Application | $36 | 0% | $36 |
Medium |
| Fluoride - Topical Application | $36 | 0% | $36 |
Medium |
| Maintenance Therapy - Periodontal | $130 | 0% | $130 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $243 | 0% | $243 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $90 | 0% | $90 |
Medium |
| Root Canal - Bicuspid Tooth | $965 | 0% | $965 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $57 | 0% | $57 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $269 | 0% | $269 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
Medium |
| X-Ray - Complete Intraoral Series | $218 | 0% | $218 |
Medium |
| X-Ray - Four Images, Bitewings | $81 | 0% | $81 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $33 | 0% | $33 |
Medium |
| X-Ray - Two Images, Bitewings | $59 | 0% | $59 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $138 | 0% | $138 |
Medium |
