| Dental Cleaning - Adult | $119 | 0% | $119 | 
Medium |
| Dental Cleaning - Child | $92 | 0% | $92 |
Medium |
| Dental Exam - Comprehensive | $106 | 0% | $106 |
Medium |
| Dental Exam - Periodic, Established Patient | $68 | 0% | $68 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $217 | 0% | $217 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $315 | 0% | $315 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $277 | 0% | $277 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $227 | 0% | $227 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $269 | 0% | $269 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $452 | 0% | $452 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $244 | 0% | $244 |
Medium |
| Fluoride - Topical Application | $53 | 0% | $53 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $310 | 0% | $310 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | 0% | $95 |
Medium |
| Root Canal - Bicuspid Tooth | $1,103 | 0% | $1,103 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $67 | 0% | $67 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $21 | 0% | $21 |
Medium |
| X-Ray - Complete Intraoral Series | $203 | 0% | $203 |
Medium |
| X-Ray - Four Images, Bitewings | $79 | 0% | $79 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $41 | 0% | $41 |
Medium |
| X-Ray - Two Images, Bitewings | $55 | 0% | $55 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $168 | 0% | $168 |
Medium |
