| Dental Cleaning - Adult | $112 | 0% | $112 | 
Medium |
| Dental Cleaning - Child | $87 | 0% | $87 |
Medium |
| Dental Exam - Comprehensive | $111 | 0% | $111 |
Medium |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $225 | 0% | $225 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $352 | 0% | $352 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $282 | 0% | $282 |
Medium |
| Flouride - Topical Varnish Application | $40 | 0% | $40 |
Medium |
| Maintenance Therapy - Periodontal | $139 | 0% | $139 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $76 | 0% | $76 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $292 | 0% | $292 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $102 | 0% | $102 |
Medium |
| Root Canal - Anterior Tooth | $1,052 | 0% | $1,052 |
Medium |
| Root Canal - Bicuspid Tooth | $1,313 | 0% | $1,313 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $67 | 0% | $67 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $228 | 0% | $228 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
Medium |
| X-Ray - Complete Intraoral Series | $161 | 0% | $161 |
Medium |
| X-Ray - Four Images, Bitewings | $79 | 0% | $79 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $56 | 0% | $56 |
Medium |
