| Dental Cleaning - Adult | $96 | 0% | $96 | 
Medium |
| Dental Cleaning - Child | $118 | 0% | $118 |
Medium |
| Dental Exam - Periodic, Established Patient | $44 | 0% | $44 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $137 | 0% | $137 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $227 | 0% | $227 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $185 | 0% | $185 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | 0% | $221 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $179 | 0% | $179 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $300 | 0% | $300 |
Medium |
| Maintenance Therapy - Periodontal | $193 | 0% | $193 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $315 | 0% | $315 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $153 | 0% | $153 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
Medium |
| X-Ray - Four Images, Bitewings | $68 | 0% | $68 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $45 | 0% | $45 |
Medium |
