| Dental Cleaning - Adult | $126 | 0% | $126 | 
Medium |
| Dental Cleaning - Child | $95 | 0% | $95 |
Medium |
| Dental Exam - Periodic, Established Patient | $68 | 0% | $68 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $210 | 0% | $210 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $315 | 0% | $315 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | 0% | $263 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $168 | 0% | $168 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $201 | 0% | $201 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $299 | 0% | $299 |
Medium |
| Flouride - Topical Varnish Application | $63 | 0% | $63 |
Medium |
| Maintenance Therapy - Periodontal | $168 | 0% | $168 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $331 | 0% | $331 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $45 | 0% | $45 |
Medium |
| X-Ray - Complete Intraoral Series | $252 | 0% | $252 |
Medium |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $47 | 0% | $47 |
Medium |
| X-Ray - Two Images, Bitewings | $68 | 0% | $68 |
Medium |
