| Dental Cleaning - Adult | $100 | 0% | $100 | 
Medium |
| Dental Cleaning - Child | $74 | 0% | $74 |
Medium |
| Dental Exam - Comprehensive | $89 | 0% | $89 |
Medium |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $167 | 0% | $167 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $315 | 0% | $315 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $213 | 0% | $213 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $167 | 0% | $167 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $184 | 0% | $184 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $315 | 0% | $315 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $213 | 0% | $213 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $213 | 0% | $213 |
Medium |
| Flouride - Topical Varnish Application | $42 | 0% | $42 |
Medium |
| Fluoride - Topical Application | $37 | 0% | $37 |
Medium |
| Maintenance Therapy - Periodontal | $142 | 0% | $142 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $64 | 0% | $64 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $263 | 0% | $263 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $79 | 0% | $79 |
Medium |
| Root Canal - Anterior Tooth | $719 | 0% | $719 |
Medium |
| Root Canal - Bicuspid Tooth | $893 | 0% | $893 |
Medium |
| Root Canal - Molar | $1,103 | 0% | $1,103 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $53 | 0% | $53 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $179 | 0% | $179 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
Medium |
| X-Ray - Complete Intraoral Series | $194 | 0% | $194 |
Medium |
| X-Ray - Four Images, Bitewings | $68 | 0% | $68 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $29 | 0% | $29 |
Medium |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $126 | 0% | $126 |
Medium |
