| Dental Cleaning - Adult | $110 | 0% | $110 | 
Medium |
| Dental Cleaning - Child | $92 | 0% | $92 |
Medium |
| Dental Exam - Comprehensive | $89 | 0% | $89 |
Medium |
| Dental Exam - Periodic, Established Patient | $54 | 0% | $54 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | 0% | $208 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $344 | 0% | $344 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $264 | 0% | $264 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $166 | 0% | $166 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $208 | 0% | $208 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $368 | 0% | $368 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | 0% | $271 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $264 | 0% | $264 |
Medium |
| Flouride - Topical Varnish Application | $59 | 0% | $59 |
Medium |
| Fluoride - Topical Application | $59 | 0% | $59 |
Medium |
| Maintenance Therapy - Periodontal | $150 | 0% | $150 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $293 | 0% | $293 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
Medium |
| Root Canal - Anterior Tooth | $1,174 | 0% | $1,174 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | 0% | $60 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $229 | 0% | $229 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
Medium |
| X-Ray - Complete Intraoral Series | $206 | 0% | $206 |
Medium |
| X-Ray - Four Images, Bitewings | $74 | 0% | $74 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
Medium |
| X-Ray - Two Images, Bitewings | $53 | 0% | $53 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $132 | 0% | $132 |
Medium |
