| Dental Cleaning - Adult | $105 | 0% | $105 | 
Medium |
| Dental Cleaning - Child | $89 | 0% | $89 |
Medium |
| Dental Exam - Comprehensive | $110 | 0% | $110 |
Medium |
| Dental Exam - Periodic, Established Patient | $56 | 0% | $56 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $239 | 0% | $239 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $383 | 0% | $383 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $270 | 0% | $270 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $249 | 0% | $249 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $239 | 0% | $239 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $383 | 0% | $383 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $269 | 0% | $269 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $270 | 0% | $270 |
Medium |
| Flouride - Topical Varnish Application | $41 | 0% | $41 |
Medium |
| Fluoride - Topical Application | $54 | 0% | $54 |
Medium |
| Maintenance Therapy - Periodontal | $159 | 0% | $159 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $107 | 0% | $107 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $302 | 0% | $302 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | 0% | $100 |
Medium |
| Root Canal - Bicuspid Tooth | $1,121 | 0% | $1,121 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | 0% | $61 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $216 | 0% | $216 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
Medium |
| X-Ray - Complete Intraoral Series | $154 | 0% | $154 |
Medium |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | 0% | $36 |
Medium |
| X-Ray - Two Images, Bitewings | $58 | 0% | $58 |
Medium |
