| Dental Cleaning - Adult | $105 | 0% | $105 | 
Medium |
| Dental Cleaning - Child | $86 | 0% | $86 |
Medium |
| Dental Exam - Comprehensive | $105 | 0% | $105 |
Medium |
| Dental Exam - Periodic, Established Patient | $50 | 0% | $50 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $214 | 0% | $214 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | 0% | $342 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | 0% | $263 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $205 | 0% | $205 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | 0% | $221 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | 0% | $342 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $248 | 0% | $248 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
Medium |
| Flouride - Topical Varnish Application | $41 | 0% | $41 |
Medium |
| Fluoride - Topical Application | $51 | 0% | $51 |
Medium |
| Maintenance Therapy - Periodontal | $151 | 0% | $151 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $107 | 0% | $107 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $276 | 0% | $276 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $90 | 0% | $90 |
Medium |
| Root Canal - Anterior Tooth | $877 | 0% | $877 |
Medium |
| Root Canal - Bicuspid Tooth | $979 | 0% | $979 |
Medium |
| Root Canal - Molar | $1,264 | 0% | $1,264 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $226 | 0% | $226 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
Medium |
| X-Ray - Complete Intraoral Series | $171 | 0% | $171 |
Medium |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
Medium |
| X-Ray - Two Images, Bitewings | $51 | 0% | $51 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $137 | 0% | $137 |
Medium |
