| Dental Cleaning - Adult | $99 | 0% | $99 | 
Medium |
| Dental Cleaning - Child | $72 | 0% | $72 |
Medium |
| Dental Exam - Comprehensive | $96 | 0% | $96 |
Medium |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $281 | 0% | $281 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $259 | 0% | $259 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $167 | 0% | $167 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $181 | 0% | $181 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $311 | 0% | $311 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $236 | 0% | $236 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $254 | 0% | $254 |
Medium |
| Fluoride - Topical Application | $48 | 0% | $48 |
Medium |
| Maintenance Therapy - Periodontal | $153 | 0% | $153 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $263 | 0% | $263 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $83 | 0% | $83 |
Medium |
| Root Canal - Molar | $1,785 | 0% | $1,785 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $57 | 0% | $57 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $193 | 0% | $193 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
Medium |
| X-Ray - Complete Intraoral Series | $146 | 0% | $146 |
Medium |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $31 | 0% | $31 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $126 | 0% | $126 |
Medium |
