| Dental Cleaning - Adult | $105 | 0% | $105 | 
Medium |
| Dental Cleaning - Child | $84 | 0% | $84 |
Medium |
| Dental Exam - Comprehensive | $90 | 0% | $90 |
Medium |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | 0% | $189 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $282 | 0% | $282 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $217 | 0% | $217 |
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 | $282 | 0% | $282 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $189 | 0% | $189 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $257 | 0% | $257 |
Medium |
| Flouride - Topical Varnish Application | $41 | 0% | $41 |
Medium |
| Fluoride - Topical Application | $42 | 0% | $42 |
Medium |
| Maintenance Therapy - Periodontal | $151 | 0% | $151 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $131 | 0% | $131 |
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 | $74 | 0% | $74 |
Medium |
| Root Canal - Anterior Tooth | $806 | 0% | $806 |
Medium |
| Root Canal - Bicuspid Tooth | $820 | 0% | $820 |
Medium |
| Root Canal - Molar | $1,219 | 0% | $1,219 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $182 | 0% | $182 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
Medium |
| X-Ray - Complete Intraoral Series | $146 | 0% | $146 |
Medium |
| X-Ray - Four Images, Bitewings | $74 | 0% | $74 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $28 | 0% | $28 |
Medium |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $130 | 0% | $130 |
Medium |
