| Dental Cleaning - Adult | $114 | 0% | $114 | 
Medium |
| Dental Cleaning - Child | $90 | 0% | $90 |
Medium |
| Dental Exam - Comprehensive | $108 | 0% | $108 |
Medium |
| Dental Exam - Periodic, Established Patient | $65 | 0% | $65 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $174 | 0% | $174 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $260 | 0% | $260 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $207 | 0% | $207 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $194 | 0% | $194 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $210 | 0% | $210 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $375 | 0% | $375 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $238 | 0% | $238 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $289 | 0% | $289 |
Medium |
| Flouride - Topical Varnish Application | $49 | 0% | $49 |
Medium |
| Maintenance Therapy - Periodontal | $169 | 0% | $169 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $308 | 0% | $308 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $102 | 0% | $102 |
Medium |
| Root Canal - Anterior Tooth | $941 | 0% | $941 |
Medium |
| Root Canal - Bicuspid Tooth | $1,072 | 0% | $1,072 |
Medium |
| Root Canal - Molar | $1,275 | 0% | $1,275 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $66 | 0% | $66 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $215 | 0% | $215 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
Medium |
| X-Ray - Complete Intraoral Series | $169 | 0% | $169 |
Medium |
| X-Ray - Four Images, Bitewings | $81 | 0% | $81 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
Medium |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
Medium |
