| Dental Cleaning - Adult | $105 | 0% | $105 | 
Medium |
| Dental Cleaning - Child | $86 | 0% | $86 |
Medium |
| Dental Exam - Comprehensive | $95 | 0% | $95 |
Medium |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $188 | 0% | $188 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $222 | 0% | $222 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $189 | 0% | $189 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $165 | 0% | $165 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | 0% | $189 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $351 | 0% | $351 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $212 | 0% | $212 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $276 | 0% | $276 |
Medium |
| Flouride - Topical Varnish Application | $49 | 0% | $49 |
Medium |
| Fluoride - Topical Application | $43 | 0% | $43 |
Medium |
| Maintenance Therapy - Periodontal | $155 | 0% | $155 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $285 | 0% | $285 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | 0% | $88 |
Medium |
| Root Canal - Bicuspid Tooth | $1,003 | 0% | $1,003 |
Medium |
| Root Canal - Molar | $2,438 | 0% | $2,438 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $183 | 0% | $183 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
Medium |
| X-Ray - Complete Intraoral Series | $153 | 0% | $153 |
Medium |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
Medium |
| X-Ray - Two Images, Bitewings | $56 | 0% | $56 |
Medium |
