| Dental Cleaning - Adult | $134 | 0% | $134 | 
Medium |
| Dental Cleaning - Child | $105 | 0% | $105 |
Medium |
| Dental Exam - Comprehensive | $142 | 0% | $142 |
Medium |
| Dental Exam - Periodic, Established Patient | $69 | 0% | $69 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $281 | 0% | $281 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $369 | 0% | $369 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $352 | 0% | $352 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $277 | 0% | $277 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $281 | 0% | $281 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $419 | 0% | $419 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $290 | 0% | $290 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $352 | 0% | $352 |
Medium |
| Flouride - Topical Varnish Application | $56 | 0% | $56 |
Medium |
| Fluoride - Topical Application | $48 | 0% | $48 |
Medium |
| Maintenance Therapy - Periodontal | $179 | 0% | $179 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $107 | 0% | $107 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $392 | 0% | $392 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $116 | 0% | $116 |
Medium |
| Root Canal - Anterior Tooth | $997 | 0% | $997 |
Medium |
| Root Canal - Bicuspid Tooth | $891 | 0% | $891 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $266 | 0% | $266 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $50 | 0% | $50 |
Medium |
| X-Ray - Complete Intraoral Series | $214 | 0% | $214 |
Medium |
| X-Ray - Four Images, Bitewings | $109 | 0% | $109 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $48 | 0% | $48 |
Medium |
| X-Ray - Two Images, Bitewings | $73 | 0% | $73 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $214 | 0% | $214 |
Medium |
