| Dental Cleaning - Adult | $117 | 0% | $117 | 
Medium |
| Dental Cleaning - Child | $93 | 0% | $93 |
Medium |
| Dental Exam - Comprehensive | $152 | 0% | $152 |
Medium |
| Dental Exam - Periodic, Established Patient | $70 | 0% | $70 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $228 | 0% | $228 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $372 | 0% | $372 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $246 | 0% | $246 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $308 | 0% | $308 |
Medium |
| Flouride - Topical Varnish Application | $61 | 0% | $61 |
Medium |
| Maintenance Therapy - Periodontal | $170 | 0% | $170 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $402 | 0% | $402 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $174 | 0% | $174 |
Medium |
| Root Canal - Molar | $1,680 | 0% | $1,680 |
Medium |
| X-Ray - Four Images, Bitewings | $78 | 0% | $78 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $71 | 0% | $71 |
Medium |
| X-Ray - Two Images, Bitewings | $82 | 0% | $82 |
Medium |
