| Dental Cleaning - Adult | $110 | 0% | $110 | 
Medium |
| Dental Cleaning - Child | $89 | 0% | $89 |
Medium |
| Dental Exam - Comprehensive | $104 | 0% | $104 |
Medium |
| Dental Exam - Periodic, Established Patient | $51 | 0% | $51 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $216 | 0% | $216 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $372 | 0% | $372 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $286 | 0% | $286 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $206 | 0% | $206 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $216 | 0% | $216 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $372 | 0% | $372 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $255 | 0% | $255 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $286 | 0% | $286 |
Medium |
| Flouride - Topical Varnish Application | $43 | 0% | $43 |
Medium |
| Maintenance Therapy - Periodontal | $160 | 0% | $160 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $92 | 0% | $92 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $331 | 0% | $331 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | 0% | $92 |
Medium |
| Root Canal - Anterior Tooth | $908 | 0% | $908 |
Medium |
| Root Canal - Bicuspid Tooth | $1,028 | 0% | $1,028 |
Medium |
| Root Canal - Molar | $1,208 | 0% | $1,208 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | 0% | $61 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $215 | 0% | $215 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
Medium |
| X-Ray - Complete Intraoral Series | $182 | 0% | $182 |
Medium |
| X-Ray - Four Images, Bitewings | $82 | 0% | $82 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | 0% | $36 |
Medium |
| X-Ray - Two Images, Bitewings | $60 | 0% | $60 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $135 | 0% | $135 |
Medium |
