| Dental Cleaning - Adult | $128 | 0% | $128 | 
Medium |
| Dental Cleaning - Child | $105 | 0% | $105 |
Medium |
| Dental Exam - Comprehensive | $135 | 0% | $135 |
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 | $419 | 0% | $419 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $270 | 0% | $270 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $277 | 0% | $277 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $237 | 0% | $237 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $419 | 0% | $419 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $329 | 0% | $329 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $335 | 0% | $335 |
Medium |
| Flouride - Topical Varnish Application | $44 | 0% | $44 |
Medium |
| Fluoride - Topical Application | $47 | 0% | $47 |
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 | $110 | 0% | $110 |
Medium |
| Root Canal - Anterior Tooth | $891 | 0% | $891 |
Medium |
| Root Canal - Bicuspid Tooth | $891 | 0% | $891 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $72 | 0% | $72 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $162 | 0% | $162 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $48 | 0% | $48 |
Medium |
| X-Ray - Complete Intraoral Series | $204 | 0% | $204 |
Medium |
| X-Ray - Four Images, Bitewings | $104 | 0% | $104 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | 0% | $46 |
Medium |
| X-Ray - Two Images, Bitewings | $71 | 0% | $71 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $214 | 0% | $214 |
Medium |
