| Dental Cleaning - Adult | $101 | 0% | $101 | 
Medium |
| Dental Cleaning - Child | $71 | 0% | $71 |
Medium |
| Dental Exam - Comprehensive | $77 | 0% | $77 |
Medium |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $143 | 0% | $143 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | 0% | $326 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $218 | 0% | $218 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $162 | 0% | $162 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $186 | 0% | $186 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $364 | 0% | $364 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $198 | 0% | $198 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $259 | 0% | $259 |
Medium |
| Flouride - Topical Varnish Application | $86 | 0% | $86 |
Medium |
| Fluoride - Topical Application | $42 | 0% | $42 |
Medium |
| Maintenance Therapy - Periodontal | $128 | 0% | $128 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $48 | 0% | $48 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $291 | 0% | $291 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $17 | 0% | $17 |
Medium |
| X-Ray - Complete Intraoral Series | $139 | 0% | $139 |
Medium |
| X-Ray - Four Images, Bitewings | $95 | 0% | $95 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $27 | 0% | $27 |
Medium |
| X-Ray - Two Images, Bitewings | $43 | 0% | $43 |
Medium |
