| Dental Cleaning - Adult | $108 | 0% | $108 | 
Medium |
| Dental Cleaning - Child | $103 | 0% | $103 |
Medium |
| Dental Exam - Comprehensive | $120 | 0% | $120 |
Medium |
| Dental Exam - Periodic, Established Patient | $50 | 0% | $50 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $338 | 0% | $338 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $270 | 0% | $270 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $234 | 0% | $234 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $234 | 0% | $234 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | 0% | $342 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $316 | 0% | $316 |
Medium |
| Flouride - Topical Varnish Application | $27 | 0% | $27 |
Medium |
| Maintenance Therapy - Periodontal | $156 | 0% | $156 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $286 | 0% | $286 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $86 | 0% | $86 |
Medium |
| Root Canal - Molar | $1,785 | 0% | $1,785 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
Medium |
| X-Ray - Complete Intraoral Series | $164 | 0% | $164 |
Medium |
| X-Ray - Four Images, Bitewings | $79 | 0% | $79 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
Medium |
