| Dental Cleaning - Adult | $126 | 0% | $126 | 
Medium |
| Dental Cleaning - Child | $116 | 0% | $116 |
Medium |
| Dental Exam - Comprehensive | $89 | 0% | $89 |
Medium |
| Dental Exam - Periodic, Established Patient | $56 | 0% | $56 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $284 | 0% | $284 |
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 | $205 | 0% | $205 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $184 | 0% | $184 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $452 | 0% | $452 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $210 | 0% | $210 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $205 | 0% | $205 |
Medium |
| Fluoride - Topical Application | $39 | 0% | $39 |
Medium |
| Maintenance Therapy - Periodontal | $263 | 0% | $263 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $77 | 0% | $77 |
Medium |
| Root Canal - Anterior Tooth | $1,313 | 0% | $1,313 |
Medium |
| Root Canal - Bicuspid Tooth | $1,103 | 0% | $1,103 |
Medium |
| Root Canal - Molar | $1,334 | 0% | $1,334 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $221 | 0% | $221 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
Medium |
| X-Ray - Complete Intraoral Series | $142 | 0% | $142 |
Medium |
| X-Ray - Four Images, Bitewings | $68 | 0% | $68 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
Medium |
| X-Ray - Two Images, Bitewings | $48 | 0% | $48 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $242 | 0% | $242 |
Medium |
