| Dental Cleaning - Adult | $104 | 0% | $104 | 
Medium |
| Dental Cleaning - Child | $120 | 0% | $120 |
Medium |
| Dental Exam - Comprehensive | $120 | 0% | $120 |
Medium |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $188 | 0% | $188 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $340 | 0% | $340 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $261 | 0% | $261 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $164 | 0% | $164 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $188 | 0% | $188 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $391 | 0% | $391 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $201 | 0% | $201 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $321 | 0% | $321 |
Medium |
| Flouride - Topical Varnish Application | $53 | 0% | $53 |
Medium |
| Fluoride - Topical Application | $53 | 0% | $53 |
Medium |
| Maintenance Therapy - Periodontal | $212 | 0% | $212 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $158 | 0% | $158 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $333 | 0% | $333 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | 0% | $88 |
Medium |
| Root Canal - Anterior Tooth | $852 | 0% | $852 |
Medium |
| Root Canal - Bicuspid Tooth | $1,541 | 0% | $1,541 |
Medium |
| Root Canal - Molar | $1,208 | 0% | $1,208 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $221 | 0% | $221 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
Medium |
| X-Ray - Complete Intraoral Series | $218 | 0% | $218 |
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 | $76 | 0% | $76 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $185 | 0% | $185 |
Medium |
