| Dental Cleaning - Adult | $130 | 0% | $130 | 
Medium |
| Dental Cleaning - Child | $101 | 0% | $101 |
Medium |
| Dental Exam - Comprehensive | $113 | 0% | $113 |
Medium |
| Dental Exam - Periodic, Established Patient | $67 | 0% | $67 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $249 | 0% | $249 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $390 | 0% | $390 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $285 | 0% | $285 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $233 | 0% | $233 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $249 | 0% | $249 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $394 | 0% | $394 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $280 | 0% | $280 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $302 | 0% | $302 |
Medium |
| Flouride - Topical Varnish Application | $50 | 0% | $50 |
Medium |
| Fluoride - Topical Application | $49 | 0% | $49 |
Medium |
| Maintenance Therapy - Periodontal | $190 | 0% | $190 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $143 | 0% | $143 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $352 | 0% | $352 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | 0% | $105 |
Medium |
| Root Canal - Anterior Tooth | $1,112 | 0% | $1,112 |
Medium |
| Root Canal - Bicuspid Tooth | $1,250 | 0% | $1,250 |
Medium |
| Root Canal - Molar | $1,510 | 0% | $1,510 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $72 | 0% | $72 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $242 | 0% | $242 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $40 | 0% | $40 |
Medium |
| X-Ray - Complete Intraoral Series | $179 | 0% | $179 |
Medium |
| X-Ray - Four Images, Bitewings | $96 | 0% | $96 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
Medium |
| X-Ray - Two Images, Bitewings | $64 | 0% | $64 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $155 | 0% | $155 |
Medium |
