| Dental Cleaning - Adult | $93 | 0% | $93 | 
Medium |
| Dental Cleaning - Child | $74 | 0% | $74 |
Medium |
| Dental Exam - Comprehensive | $79 | 0% | $79 |
Medium |
| Dental Exam - Periodic, Established Patient | $42 | 0% | $42 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $179 | 0% | $179 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $268 | 0% | $268 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $215 | 0% | $215 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $179 | 0% | $179 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $268 | 0% | $268 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $189 | 0% | $189 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $215 | 0% | $215 |
Medium |
| Fluoride - Topical Application | $37 | 0% | $37 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $115 | 0% | $115 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $74 | 0% | $74 |
Medium |
| Root Canal - Anterior Tooth | $683 | 0% | $683 |
Medium |
| Root Canal - Bicuspid Tooth | $840 | 0% | $840 |
Medium |
| Root Canal - Molar | $1,050 | 0% | $1,050 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $189 | 0% | $189 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $21 | 0% | $21 |
Medium |
| X-Ray - Four Images, Bitewings | $63 | 0% | $63 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $26 | 0% | $26 |
Medium |
| X-Ray - Two Images, Bitewings | $42 | 0% | $42 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $110 | 0% | $110 |
Medium |
