| Dental Cleaning - Adult | $112 | 0% | $112 | 
Medium |
| Dental Cleaning - Child | $90 | 0% | $90 |
Medium |
| Dental Exam - Comprehensive | $105 | 0% | $105 |
Medium |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $213 | 0% | $213 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $284 | 0% | $284 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $193 | 0% | $193 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $213 | 0% | $213 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $368 | 0% | $368 |
Medium |
| Flouride - Topical Varnish Application | $44 | 0% | $44 |
Medium |
| Fluoride - Topical Application | $46 | 0% | $46 |
Medium |
| Root Canal - Anterior Tooth | $1,038 | 0% | $1,038 |
Medium |
| X-Ray - Complete Intraoral Series | $158 | 0% | $158 |
Medium |
| X-Ray - Four Images, Bitewings | $79 | 0% | $79 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $54 | 0% | $54 |
Medium |
