| Dental Cleaning - Adult | $144 | 0% | $144 | 
Medium |
| Dental Cleaning - Child | $106 | 0% | $106 |
Medium |
| Dental Exam - Comprehensive | $127 | 0% | $127 |
Medium |
| Dental Exam - Periodic, Established Patient | $69 | 0% | $69 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $329 | 0% | $329 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $208 | 0% | $208 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $300 | 0% | $300 |
Medium |
| Flouride - Topical Varnish Application | $55 | 0% | $55 |
Medium |
| Fluoride - Topical Application | $46 | 0% | $46 |
Medium |
| Maintenance Therapy - Periodontal | $187 | 0% | $187 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $315 | 0% | $315 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | 0% | $101 |
Medium |
| Root Canal - Molar | $1,534 | 0% | $1,534 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $100 | 0% | $100 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $251 | 0% | $251 |
Medium |
| X-Ray - Complete Intraoral Series | $201 | 0% | $201 |
Medium |
| X-Ray - Four Images, Bitewings | $87 | 0% | $87 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
Medium |
