| Dental Cleaning - Adult | $126 | 0% | $126 | 
Medium |
| Dental Cleaning - Child | $110 | 0% | $110 |
Medium |
| Dental Exam - Comprehensive | $84 | 0% | $84 |
Medium |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $179 | 0% | $179 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $221 | 0% | $221 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $200 | 0% | $200 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $261 | 0% | $261 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $179 | 0% | $179 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $441 | 0% | $441 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $200 | 0% | $200 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $200 | 0% | $200 |
Medium |
| Fluoride - Topical Application | $37 | 0% | $37 |
Medium |
| Maintenance Therapy - Periodontal | $173 | 0% | $173 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $174 | 0% | $174 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $77 | 0% | $77 |
Medium |
| Root Canal - Anterior Tooth | $840 | 0% | $840 |
Medium |
| Root Canal - Bicuspid Tooth | $1,050 | 0% | $1,050 |
Medium |
| Root Canal - Molar | $1,334 | 0% | $1,334 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $56 | 0% | $56 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $305 | 0% | $305 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $24 | 0% | $24 |
Medium |
| X-Ray - Complete Intraoral Series | $139 | 0% | $139 |
Medium |
| X-Ray - Four Images, Bitewings | $65 | 0% | $65 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
Medium |
| X-Ray - Two Images, Bitewings | $46 | 0% | $46 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $242 | 0% | $242 |
Medium |
