| Dental Cleaning - Adult | $120 | 0% | $120 | 
Medium |
| Dental Cleaning - Child | $95 | 0% | $95 |
Medium |
| Dental Exam - Comprehensive | $111 | 0% | $111 |
Medium |
| Dental Exam - Periodic, Established Patient | $71 | 0% | $71 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $154 | 0% | $154 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $212 | 0% | $212 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $189 | 0% | $189 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $156 | 0% | $156 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $167 | 0% | $167 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $255 | 0% | $255 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $178 | 0% | $178 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $198 | 0% | $198 |
Medium |
| Flouride - Topical Varnish Application | $43 | 0% | $43 |
Medium |
| Fluoride - Topical Application | $43 | 0% | $43 |
Medium |
| Root Canal - Bicuspid Tooth | $1,155 | 0% | $1,155 |
Medium |
| Root Canal - Molar | $1,297 | 0% | $1,297 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $215 | 0% | $215 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
Medium |
| X-Ray - Complete Intraoral Series | $234 | 0% | $234 |
Medium |
| X-Ray - Four Images, Bitewings | $70 | 0% | $70 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
Medium |
| X-Ray - Two Images, Bitewings | $46 | 0% | $46 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $174 | 0% | $174 |
Medium |
