| Dental Cleaning - Adult | $116 | 0% | $116 | 
Medium |
| Dental Cleaning - Child | $85 | 0% | $85 |
Medium |
| Dental Exam - Comprehensive | $110 | 0% | $110 |
Medium |
| Dental Exam - Periodic, Established Patient | $64 | 0% | $64 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $223 | 0% | $223 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $369 | 0% | $369 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $282 | 0% | $282 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $207 | 0% | $207 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $223 | 0% | $223 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $369 | 0% | $369 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $251 | 0% | $251 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $282 | 0% | $282 |
Medium |
| Flouride - Topical Varnish Application | $55 | 0% | $55 |
Medium |
| Fluoride - Topical Application | $45 | 0% | $45 |
Medium |
| Maintenance Therapy - Periodontal | $174 | 0% | $174 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $60 | 0% | $60 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $306 | 0% | $306 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | 0% | $100 |
Medium |
| Root Canal - Anterior Tooth | $929 | 0% | $929 |
Medium |
| Root Canal - Bicuspid Tooth | $1,071 | 0% | $1,071 |
Medium |
| Root Canal - Molar | $1,298 | 0% | $1,298 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | 0% | $68 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $227 | 0% | $227 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
Medium |
| X-Ray - Complete Intraoral Series | $210 | 0% | $210 |
Medium |
| X-Ray - Four Images, Bitewings | $86 | 0% | $86 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $58 | 0% | $58 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $153 | 0% | $153 |
Medium |
