| Dental Cleaning - Adult | $128 | 0% | $128 | 
Medium |
| Dental Cleaning - Child | $99 | 0% | $99 |
Medium |
| Dental Exam - Comprehensive | $112 | 0% | $112 |
Medium |
| Dental Exam - Periodic, Established Patient | $66 | 0% | $66 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $227 | 0% | $227 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $378 | 0% | $378 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $282 | 0% | $282 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $227 | 0% | $227 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $227 | 0% | $227 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $390 | 0% | $390 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $280 | 0% | $280 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $285 | 0% | $285 |
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 | $336 | 0% | $336 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $107 | 0% | $107 |
Medium |
| Root Canal - Anterior Tooth | $1,069 | 0% | $1,069 |
Medium |
| Root Canal - Bicuspid Tooth | $1,260 | 0% | $1,260 |
Medium |
| Root Canal - Molar | $1,451 | 0% | $1,451 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | 0% | $71 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $236 | 0% | $236 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $39 | 0% | $39 |
Medium |
| X-Ray - Complete Intraoral Series | $176 | 0% | $176 |
Medium |
| X-Ray - Four Images, Bitewings | $93 | 0% | $93 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
Medium |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $155 | 0% | $155 |
Medium |
