| Dental Cleaning - Adult | $104 | 0% | $104 | 
Medium |
| Dental Cleaning - Child | $84 | 0% | $84 |
Medium |
| Dental Exam - Comprehensive | $100 | 0% | $100 |
Medium |
| Dental Exam - Periodic, Established Patient | $55 | 0% | $55 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $200 | 0% | $200 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $341 | 0% | $341 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $273 | 0% | $273 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $200 | 0% | $200 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $200 | 0% | $200 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $341 | 0% | $341 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $273 | 0% | $273 |
Medium |
| Flouride - Topical Varnish Application | $42 | 0% | $42 |
Medium |
| Fluoride - Topical Application | $43 | 0% | $43 |
Medium |
| Maintenance Therapy - Periodontal | $150 | 0% | $150 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $299 | 0% | $299 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | 0% | $88 |
Medium |
| Root Canal - Bicuspid Tooth | $1,208 | 0% | $1,208 |
Medium |
| Root Canal - Molar | $1,365 | 0% | $1,365 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $347 | 0% | $347 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
Medium |
| X-Ray - Complete Intraoral Series | $147 | 0% | $147 |
Medium |
| X-Ray - Four Images, Bitewings | $76 | 0% | $76 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
Medium |
| X-Ray - Two Images, Bitewings | $58 | 0% | $58 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $147 | 0% | $147 |
Medium |
