| Dental Cleaning - Adult | $99 | 0% | $99 | 
Medium |
| Dental Cleaning - Child | $99 | 0% | $99 |
Medium |
| Dental Exam - Comprehensive | $96 | 0% | $96 |
Medium |
| Dental Exam - Periodic, Established Patient | $54 | 0% | $54 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $184 | 0% | $184 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $311 | 0% | $311 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $242 | 0% | $242 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $167 | 0% | $167 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $193 | 0% | $193 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $296 | 0% | $296 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $213 | 0% | $213 |
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 | $275 | 0% | $275 |
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 | $26 | 0% | $26 |
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 | $30 | 0% | $30 |
Medium |
| X-Ray - Two Images, Bitewings | $76 | 0% | $76 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $152 | 0% | $152 |
Medium |
