| Dental Cleaning - Adult | $113 | 0% | $113 | 
Medium |
| Dental Cleaning - Child | $89 | 0% | $89 |
Medium |
| Dental Exam - Comprehensive | $101 | 0% | $101 |
Medium |
| Dental Exam - Periodic, Established Patient | $50 | 0% | $50 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $190 | 0% | $190 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $338 | 0% | $338 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $266 | 0% | $266 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $190 | 0% | $190 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $190 | 0% | $190 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $676 | 0% | $676 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $266 | 0% | $266 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $266 | 0% | $266 |
Medium |
| Fluoride - Topical Application | $43 | 0% | $43 |
Medium |
| Maintenance Therapy - Periodontal | $156 | 0% | $156 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $98 | 0% | $98 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $271 | 0% | $271 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $97 | 0% | $97 |
Medium |
| Root Canal - Anterior Tooth | $866 | 0% | $866 |
Medium |
| Root Canal - Bicuspid Tooth | $987 | 0% | $987 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | 0% | $33 |
Medium |
| X-Ray - Complete Intraoral Series | $162 | 0% | $162 |
Medium |
| X-Ray - Four Images, Bitewings | $75 | 0% | $75 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $55 | 0% | $55 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $156 | 0% | $156 |
Medium |
