| Dental Cleaning - Adult | $111 | 0% | $111 | 
Medium |
| Dental Cleaning - Child | $84 | 0% | $84 |
Medium |
| Dental Exam - Comprehensive | $101 | 0% | $101 |
Medium |
| Dental Exam - Periodic, Established Patient | $62 | 0% | $62 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $336 | 0% | $336 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $231 | 0% | $231 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $218 | 0% | $218 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $344 | 0% | $344 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $284 | 0% | $284 |
Medium |
| Fluoride - Topical Application | $46 | 0% | $46 |
Medium |
| Maintenance Therapy - Periodontal | $167 | 0% | $167 |
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 | $91 | 0% | $91 |
Medium |
| Root Canal - Bicuspid Tooth | $1,325 | 0% | $1,325 |
Medium |
| Root Canal - Molar | $1,271 | 0% | $1,271 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
Medium |
| X-Ray - Complete Intraoral Series | $160 | 0% | $160 |
Medium |
| X-Ray - Four Images, Bitewings | $80 | 0% | $80 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $68 | 0% | $68 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $137 | 0% | $137 |
Medium |
