| Dental Cleaning - Adult | $89 | 0% | $89 | 
Medium |
| Dental Cleaning - Child | $68 | 0% | $68 |
Medium |
| Dental Exam - Comprehensive | $74 | 0% | $74 |
Medium |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $142 | 0% | $142 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $200 | 0% | $200 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $179 | 0% | $179 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $158 | 0% | $158 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $362 | 0% | $362 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $263 | 0% | $263 |
Medium |
| Fluoride - Topical Application | $53 | 0% | $53 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $53 | 0% | $53 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $16 | 0% | $16 |
Medium |
| X-Ray - Complete Intraoral Series | $158 | 0% | $158 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
Medium |
| X-Ray - Two Images, Bitewings | $53 | 0% | $53 |
Medium |
