| Dental Cleaning - Adult | $103 | 0% | $103 | 
Medium |
| Dental Cleaning - Child | $83 | 0% | $83 |
Medium |
| Dental Exam - Comprehensive | $90 | 0% | $90 |
Medium |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $186 | 0% | $186 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $337 | 0% | $337 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $259 | 0% | $259 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $169 | 0% | $169 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $186 | 0% | $186 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $337 | 0% | $337 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $208 | 0% | $208 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $259 | 0% | $259 |
Medium |
| Flouride - Topical Varnish Application | $46 | 0% | $46 |
Medium |
| Maintenance Therapy - Periodontal | $149 | 0% | $149 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $272 | 0% | $272 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $87 | 0% | $87 |
Medium |
| Root Canal - Anterior Tooth | $759 | 0% | $759 |
Medium |
| Root Canal - Bicuspid Tooth | $865 | 0% | $865 |
Medium |
| Root Canal - Molar | $2,039 | 0% | $2,039 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $185 | 0% | $185 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $16 | 0% | $16 |
Medium |
| X-Ray - Complete Intraoral Series | $144 | 0% | $144 |
Medium |
| X-Ray - Four Images, Bitewings | $70 | 0% | $70 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $16 | 0% | $16 |
Medium |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $127 | 0% | $127 |
Medium |
