| Dental Cleaning - Adult | $104 | 0% | $104 | 
Medium |
| Dental Cleaning - Child | $89 | 0% | $89 |
Medium |
| Dental Exam - Comprehensive | $96 | 0% | $96 |
Medium |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $194 | 0% | $194 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $341 | 0% | $341 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $273 | 0% | $273 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $173 | 0% | $173 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $194 | 0% | $194 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $341 | 0% | $341 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $209 | 0% | $209 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $278 | 0% | $278 |
Medium |
| Flouride - Topical Varnish Application | $43 | 0% | $43 |
Medium |
| Fluoride - Topical Application | $48 | 0% | $48 |
Medium |
| Maintenance Therapy - Periodontal | $168 | 0% | $168 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $93 | 0% | $93 |
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 | $95 | 0% | $95 |
Medium |
| Root Canal - Anterior Tooth | $966 | 0% | $966 |
Medium |
| Root Canal - Bicuspid Tooth | $1,028 | 0% | $1,028 |
Medium |
| Root Canal - Molar | $1,224 | 0% | $1,224 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $202 | 0% | $202 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | 0% | $36 |
Medium |
| X-Ray - Complete Intraoral Series | $158 | 0% | $158 |
Medium |
| X-Ray - Four Images, Bitewings | $86 | 0% | $86 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $67 | 0% | $67 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $158 | 0% | $158 |
Medium |
