| Dental Cleaning - Adult | $126 | 0% | $126 | 
Medium |
| Dental Cleaning - Child | $105 | 0% | $105 |
Medium |
| Dental Exam - Comprehensive | $116 | 0% | $116 |
Medium |
| Dental Exam - Periodic, Established Patient | $68 | 0% | $68 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $399 | 0% | $399 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $578 | 0% | $578 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $483 | 0% | $483 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $315 | 0% | $315 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $399 | 0% | $399 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $433 | 0% | $433 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $389 | 0% | $389 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $483 | 0% | $483 |
Medium |
| Fluoride - Topical Application | $63 | 0% | $63 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | 0% | $74 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $368 | 0% | $368 |
Medium |
| X-Ray - Complete Intraoral Series | $184 | 0% | $184 |
Medium |
| X-Ray - Two Images, Bitewings | $74 | 0% | $74 |
Medium |
