| Dental Cleaning - Adult | $101 | 0% | $101 | 
Medium |
| Dental Cleaning - Child | $64 | 0% | $64 |
Medium |
| Dental Exam - Comprehensive | $121 | 0% | $121 |
Medium |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $201 | 0% | $201 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $354 | 0% | $354 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $257 | 0% | $257 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $186 | 0% | $186 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $212 | 0% | $212 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $323 | 0% | $323 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $212 | 0% | $212 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $254 | 0% | $254 |
Medium |
| Flouride - Topical Varnish Application | $45 | 0% | $45 |
Medium |
| Fluoride - Topical Application | $33 | 0% | $33 |
Medium |
| Maintenance Therapy - Periodontal | $135 | 0% | $135 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $134 | 0% | $134 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $249 | 0% | $249 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $83 | 0% | $83 |
Medium |
| Root Canal - Bicuspid Tooth | $1,307 | 0% | $1,307 |
Medium |
| Root Canal - Molar | $1,184 | 0% | $1,184 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | 0% | $60 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $275 | 0% | $275 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
Medium |
| X-Ray - Complete Intraoral Series | $139 | 0% | $139 |
Medium |
| X-Ray - Four Images, Bitewings | $68 | 0% | $68 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $33 | 0% | $33 |
Medium |
| X-Ray - Two Images, Bitewings | $57 | 0% | $57 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $134 | 0% | $134 |
Medium |
