| Dental Cleaning - Adult | $116 | 0% | $116 | 
Medium |
| Dental Cleaning - Child | $89 | 0% | $89 |
Medium |
| Dental Exam - Comprehensive | $95 | 0% | $95 |
Medium |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $236 | 0% | $236 |
Medium |
| Flouride - Topical Varnish Application | $48 | 0% | $48 |
Medium |
| Maintenance Therapy - Periodontal | $162 | 0% | $162 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
Medium |
| Root Canal - Anterior Tooth | $893 | 0% | $893 |
Medium |
| Root Canal - Bicuspid Tooth | $971 | 0% | $971 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $200 | 0% | $200 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
Medium |
| X-Ray - Complete Intraoral Series | $173 | 0% | $173 |
Medium |
| X-Ray - Four Images, Bitewings | $80 | 0% | $80 |
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 | $294 | 0% | $294 |
Medium |
