| Dental Cleaning - Adult | $113 | 0% | $113 | 
Medium |
| Dental Exam - Comprehensive | $110 | 0% | $110 |
Medium |
| Dental Exam - Periodic, Established Patient | $50 | 0% | $50 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $218 | 0% | $218 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $208 | 0% | $208 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $369 | 0% | $369 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $270 | 0% | $270 |
Medium |
| Maintenance Therapy - Periodontal | $164 | 0% | $164 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $386 | 0% | $386 |
Medium |
| Root Canal - Bicuspid Tooth | $1,541 | 0% | $1,541 |
Medium |
| Root Canal - Molar | $1,595 | 0% | $1,595 |
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 | $37 | 0% | $37 |
Medium |
