| Dental Cleaning - Adult | $114 | 0% | $114 | 
Medium |
| Dental Cleaning - Child | $84 | 0% | $84 |
Medium |
| Dental Exam - Comprehensive | $108 | 0% | $108 |
Medium |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
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 | $314 | 0% | $314 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $219 | 0% | $219 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $238 | 0% | $238 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $398 | 0% | $398 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $290 | 0% | $290 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $323 | 0% | $323 |
Medium |
| Flouride - Topical Varnish Application | $50 | 0% | $50 |
Medium |
| Fluoride - Topical Application | $42 | 0% | $42 |
Medium |
| Maintenance Therapy - Periodontal | $174 | 0% | $174 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $59 | 0% | $59 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $305 | 0% | $305 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $96 | 0% | $96 |
Medium |
| Root Canal - Anterior Tooth | $1,425 | 0% | $1,425 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | 0% | $69 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $229 | 0% | $229 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
Medium |
| X-Ray - Complete Intraoral Series | $165 | 0% | $165 |
Medium |
| X-Ray - Four Images, Bitewings | $75 | 0% | $75 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
Medium |
| X-Ray - Two Images, Bitewings | $57 | 0% | $57 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $139 | 0% | $139 |
Medium |
