| Dental Cleaning - Adult | $129 | 0% | $129 | 
Medium |
| Dental Cleaning - Child | $101 | 0% | $101 |
Medium |
| Dental Exam - Comprehensive | $106 | 0% | $106 |
Medium |
| Dental Exam - Periodic, Established Patient | $57 | 0% | $57 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $226 | 0% | $226 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $247 | 0% | $247 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $294 | 0% | $294 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $194 | 0% | $194 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $226 | 0% | $226 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $377 | 0% | $377 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $233 | 0% | $233 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $294 | 0% | $294 |
Medium |
| Flouride - Topical Varnish Application | $46 | 0% | $46 |
Medium |
| Fluoride - Topical Application | $47 | 0% | $47 |
Medium |
| Maintenance Therapy - Periodontal | $174 | 0% | $174 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $93 | 0% | $93 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $318 | 0% | $318 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $97 | 0% | $97 |
Medium |
| Root Canal - Anterior Tooth | $1,179 | 0% | $1,179 |
Medium |
| Root Canal - Bicuspid Tooth | $1,446 | 0% | $1,446 |
Medium |
| Root Canal - Molar | $1,691 | 0% | $1,691 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | 0% | $69 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $216 | 0% | $216 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
Medium |
| X-Ray - Complete Intraoral Series | $172 | 0% | $172 |
Medium |
| X-Ray - Four Images, Bitewings | $83 | 0% | $83 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $57 | 0% | $57 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $155 | 0% | $155 |
Medium |
