| Dental Cleaning - Child | $64 | 0% | $64 | 
Medium |
| Dental Exam - Comprehensive | $81 | 0% | $81 |
Medium |
| Dental Exam - Periodic, Established Patient | $40 | 0% | $40 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $142 | 0% | $142 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $228 | 0% | $228 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $194 | 0% | $194 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $142 | 0% | $142 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $142 | 0% | $142 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $273 | 0% | $273 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $194 | 0% | $194 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $194 | 0% | $194 |
Medium |
| Root Canal - Bicuspid Tooth | $998 | 0% | $998 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $47 | 0% | $47 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $158 | 0% | $158 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $21 | 0% | $21 |
Medium |
| X-Ray - Complete Intraoral Series | $142 | 0% | $142 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $26 | 0% | $26 |
Medium |
| X-Ray - Two Images, Bitewings | $41 | 0% | $41 |
Medium |
