| Dental Cleaning - Adult | $100 | 0% | $100 | 
Medium |
| Dental Cleaning - Child | $74 | 0% | $74 |
Medium |
| Dental Exam - Periodic, Established Patient | $57 | 0% | $57 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $191 | 0% | $191 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $290 | 0% | $290 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $236 | 0% | $236 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $191 | 0% | $191 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $301 | 0% | $301 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $246 | 0% | $246 |
Medium |
| Flouride - Topical Varnish Application | $46 | 0% | $46 |
Medium |
| Maintenance Therapy - Periodontal | $131 | 0% | $131 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $315 | 0% | $315 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | 0% | $184 |
Medium |
| X-Ray - Complete Intraoral Series | $172 | 0% | $172 |
Medium |
| X-Ray - Four Images, Bitewings | $74 | 0% | $74 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
Medium |
| X-Ray - Two Images, Bitewings | $48 | 0% | $48 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $126 | 0% | $126 |
Medium |
