| Dental Cleaning - Adult | $103 | 0% | $103 | 
Medium |
| Dental Cleaning - Child | $84 | 0% | $84 |
Medium |
| Dental Exam - Comprehensive | $99 | 0% | $99 |
Medium |
| Dental Exam - Periodic, Established Patient | $50 | 0% | $50 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | 0% | $208 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | 0% | $326 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $200 | 0% | $200 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $165 | 0% | $165 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $211 | 0% | $211 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $341 | 0% | $341 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $223 | 0% | $223 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $321 | 0% | $321 |
Medium |
| Fluoride - Topical Application | $58 | 0% | $58 |
Medium |
| Maintenance Therapy - Periodontal | $212 | 0% | $212 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $273 | 0% | $273 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
Medium |
| Root Canal - Anterior Tooth | $893 | 0% | $893 |
Medium |
| Root Canal - Bicuspid Tooth | $998 | 0% | $998 |
Medium |
| Root Canal - Molar | $1,229 | 0% | $1,229 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | 0% | $61 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $210 | 0% | $210 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
Medium |
| X-Ray - Complete Intraoral Series | $147 | 0% | $147 |
Medium |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
Medium |
| X-Ray - Two Images, Bitewings | $53 | 0% | $53 |
Medium |
