| Dental Cleaning - Adult | $107 | 0% | $107 | 
Medium |
| Dental Cleaning - Child | $89 | 0% | $89 |
Medium |
| Dental Exam - Comprehensive | $102 | 0% | $102 |
Medium |
| Dental Exam - Periodic, Established Patient | $51 | 0% | $51 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | 0% | $189 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $224 | 0% | $224 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $187 | 0% | $187 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $187 | 0% | $187 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $226 | 0% | $226 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $341 | 0% | $341 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $224 | 0% | $224 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $278 | 0% | $278 |
Medium |
| Flouride - Topical Varnish Application | $46 | 0% | $46 |
Medium |
| Fluoride - Topical Application | $37 | 0% | $37 |
Medium |
| Maintenance Therapy - Periodontal | $147 | 0% | $147 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $278 | 0% | $278 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $104 | 0% | $104 |
Medium |
| Root Canal - Anterior Tooth | $1,733 | 0% | $1,733 |
Medium |
| Root Canal - Bicuspid Tooth | $995 | 0% | $995 |
Medium |
| Root Canal - Molar | $1,213 | 0% | $1,213 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | 0% | $71 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $209 | 0% | $209 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
Medium |
| X-Ray - Complete Intraoral Series | $146 | 0% | $146 |
Medium |
| X-Ray - Four Images, Bitewings | $82 | 0% | $82 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
Medium |
| X-Ray - Two Images, Bitewings | $56 | 0% | $56 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $131 | 0% | $131 |
Medium |
