| Dental Cleaning - Adult | $109 | 0% | $109 | 
Medium |
| Dental Cleaning - Child | $90 | 0% | $90 |
Medium |
| Dental Exam - Comprehensive | $111 | 0% | $111 |
Medium |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
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 | $192 | 0% | $192 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $189 | 0% | $189 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | 0% | $189 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | 0% | $342 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $227 | 0% | $227 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
Medium |
| Flouride - Topical Varnish Application | $48 | 0% | $48 |
Medium |
| Maintenance Therapy - Periodontal | $231 | 0% | $231 |
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 | $106 | 0% | $106 |
Medium |
| Root Canal - Anterior Tooth | $940 | 0% | $940 |
Medium |
| Root Canal - Bicuspid Tooth | $1,035 | 0% | $1,035 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | 0% | $71 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $212 | 0% | $212 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $41 | 0% | $41 |
Medium |
| X-Ray - Complete Intraoral Series | $148 | 0% | $148 |
Medium |
| X-Ray - Four Images, Bitewings | $83 | 0% | $83 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
Medium |
| X-Ray - Two Images, Bitewings | $57 | 0% | $57 |
Medium |
