| Dental Cleaning - Adult | $111 | 0% | $111 | 
Medium |
| Dental Cleaning - Child | $85 | 0% | $85 |
Medium |
| Dental Exam - Comprehensive | $105 | 0% | $105 |
Medium |
| Dental Exam - Periodic, Established Patient | $61 | 0% | $61 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $209 | 0% | $209 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $350 | 0% | $350 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $271 | 0% | $271 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $202 | 0% | $202 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $209 | 0% | $209 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $350 | 0% | $350 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $235 | 0% | $235 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $271 | 0% | $271 |
Medium |
| Flouride - Topical Varnish Application | $53 | 0% | $53 |
Medium |
| Fluoride - Topical Application | $53 | 0% | $53 |
Medium |
| Maintenance Therapy - Periodontal | $168 | 0% | $168 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $121 | 0% | $121 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $289 | 0% | $289 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $96 | 0% | $96 |
Medium |
| Root Canal - Anterior Tooth | $1,345 | 0% | $1,345 |
Medium |
| Root Canal - Bicuspid Tooth | $1,071 | 0% | $1,071 |
Medium |
| Root Canal - Molar | $1,263 | 0% | $1,263 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $65 | 0% | $65 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $201 | 0% | $201 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
Medium |
| X-Ray - Complete Intraoral Series | $209 | 0% | $209 |
Medium |
| X-Ray - Four Images, Bitewings | $79 | 0% | $79 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
Medium |
| X-Ray - Two Images, Bitewings | $58 | 0% | $58 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $145 | 0% | $145 |
Medium |
