| Dental Cleaning - Adult | $104 | 0% | $104 | 
Medium |
| Dental Cleaning - Child | $120 | 0% | $120 |
Medium |
| Dental Exam - Comprehensive | $106 | 0% | $106 |
Medium |
| Dental Exam - Periodic, Established Patient | $74 | 0% | $74 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $198 | 0% | $198 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | 0% | $326 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $187 | 0% | $187 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | 0% | $184 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $233 | 0% | $233 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $352 | 0% | $352 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | 0% | $271 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $284 | 0% | $284 |
Medium |
| Fluoride - Topical Application | $69 | 0% | $69 |
Medium |
| Maintenance Therapy - Periodontal | $212 | 0% | $212 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $395 | 0% | $395 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $113 | 0% | $113 |
Medium |
| Root Canal - Anterior Tooth | $1,323 | 0% | $1,323 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $80 | 0% | $80 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $214 | 0% | $214 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $17 | 0% | $17 |
Medium |
| X-Ray - Complete Intraoral Series | $148 | 0% | $148 |
Medium |
| X-Ray - Four Images, Bitewings | $77 | 0% | $77 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
Medium |
| X-Ray - Two Images, Bitewings | $76 | 0% | $76 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $130 | 0% | $130 |
Medium |
