| Dental Cleaning - Adult | $111 | 0% | $111 | 
Medium |
| Dental Cleaning - Child | $82 | 0% | $82 |
Medium |
| Dental Exam - Comprehensive | $105 | 0% | $105 |
Medium |
| Dental Exam - Periodic, Established Patient | $61 | 0% | $61 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $231 | 0% | $231 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $398 | 0% | $398 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $305 | 0% | $305 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $213 | 0% | $213 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $231 | 0% | $231 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $398 | 0% | $398 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $281 | 0% | $281 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $314 | 0% | $314 |
Medium |
| Flouride - Topical Varnish Application | $49 | 0% | $49 |
Medium |
| Fluoride - Topical Application | $42 | 0% | $42 |
Medium |
| Maintenance Therapy - Periodontal | $169 | 0% | $169 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $59 | 0% | $59 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $300 | 0% | $300 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | 0% | $92 |
Medium |
| Root Canal - Anterior Tooth | $1,383 | 0% | $1,383 |
Medium |
| Root Canal - Bicuspid Tooth | $1,568 | 0% | $1,568 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | 0% | $69 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $223 | 0% | $223 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
Medium |
| X-Ray - Complete Intraoral Series | $160 | 0% | $160 |
Medium |
| X-Ray - Four Images, Bitewings | $72 | 0% | $72 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
Medium |
| X-Ray - Two Images, Bitewings | $55 | 0% | $55 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $134 | 0% | $134 |
Medium |
