| Dental Cleaning - Adult | $126 | 0% | $126 | 
Medium |
| Dental Cleaning - Child | $126 | 0% | $126 |
Medium |
| Dental Exam - Comprehensive | $147 | 0% | $147 |
Medium |
| Dental Exam - Periodic, Established Patient | $84 | 0% | $84 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $315 | 0% | $315 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $420 | 0% | $420 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $210 | 0% | $210 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $315 | 0% | $315 |
Medium |
| Fluoride - Topical Application | $63 | 0% | $63 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $368 | 0% | $368 |
Medium |
| Root Canal - Bicuspid Tooth | $2,310 | 0% | $2,310 |
Medium |
| Root Canal - Molar | $2,258 | 0% | $2,258 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $210 | 0% | $210 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $210 | 0% | $210 |
Medium |
