| Dental Cleaning - Adult | $137 | 0% | $137 | 
Medium |
| Dental Cleaning - Child | $79 | 0% | $79 |
Medium |
| Dental Exam - Comprehensive | $148 | 0% | $148 |
Medium |
| Dental Exam - Periodic, Established Patient | $61 | 0% | $61 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $288 | 0% | $288 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $438 | 0% | $438 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $369 | 0% | $369 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $273 | 0% | $273 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $288 | 0% | $288 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $460 | 0% | $460 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $303 | 0% | $303 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $369 | 0% | $369 |
Medium |
| Flouride - Topical Varnish Application | $70 | 0% | $70 |
Medium |
| Maintenance Therapy - Periodontal | $214 | 0% | $214 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $341 | 0% | $341 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $113 | 0% | $113 |
Medium |
| Root Canal - Anterior Tooth | $1,153 | 0% | $1,153 |
Medium |
| Root Canal - Molar | $1,468 | 0% | $1,468 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | 0% | $69 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $260 | 0% | $260 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
Medium |
| X-Ray - Complete Intraoral Series | $176 | 0% | $176 |
Medium |
| X-Ray - Four Images, Bitewings | $99 | 0% | $99 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
Medium |
| X-Ray - Two Images, Bitewings | $74 | 0% | $74 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $214 | 0% | $214 |
Medium |
