| Dental Cleaning - Adult | $126 | 0% | $126 | 
Medium |
| Dental Cleaning - Child | $92 | 0% | $92 |
Medium |
| Dental Exam - Comprehensive | $126 | 0% | $126 |
Medium |
| Dental Exam - Periodic, Established Patient | $70 | 0% | $70 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $330 | 0% | $330 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $227 | 0% | $227 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $256 | 0% | $256 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $410 | 0% | $410 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $330 | 0% | $330 |
Medium |
| Flouride - Topical Varnish Application | $28 | 0% | $28 |
Medium |
| Fluoride - Topical Application | $44 | 0% | $44 |
Medium |
| Maintenance Therapy - Periodontal | $182 | 0% | $182 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $75 | 0% | $75 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $266 | 0% | $266 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
Medium |
| X-Ray - Complete Intraoral Series | $175 | 0% | $175 |
Medium |
| X-Ray - Four Images, Bitewings | $90 | 0% | $90 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
Medium |
