| Dental Cleaning - Adult | $118 | 0% | $118 | 
Medium |
| Dental Exam - Comprehensive | $109 | 0% | $109 |
Medium |
| Dental Exam - Periodic, Established Patient | $62 | 0% | $62 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $223 | 0% | $223 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $333 | 0% | $333 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $286 | 0% | $286 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $223 | 0% | $223 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $286 | 0% | $286 |
Medium |
| Flouride - Topical Varnish Application | $53 | 0% | $53 |
Medium |
| Fluoride - Topical Application | $47 | 0% | $47 |
Medium |
| Maintenance Therapy - Periodontal | $163 | 0% | $163 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $299 | 0% | $299 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | 0% | $101 |
Medium |
| Root Canal - Molar | $1,386 | 0% | $1,386 |
Medium |
| X-Ray - Complete Intraoral Series | $155 | 0% | $155 |
Medium |
| X-Ray - Four Images, Bitewings | $89 | 0% | $89 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
Medium |
