| Dental Cleaning - Adult | $116 | 0% | $116 | 
Medium |
| Dental Cleaning - Child | $95 | 0% | $95 |
Medium |
| Dental Exam - Comprehensive | $79 | 0% | $79 |
Medium |
| Dental Exam - Periodic, Established Patient | $46 | 0% | $46 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $168 | 0% | $168 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $236 | 0% | $236 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $305 | 0% | $305 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $252 | 0% | $252 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $284 | 0% | $284 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $189 | 0% | $189 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $354 | 0% | $354 |
Medium |
| Fluoride - Topical Application | $47 | 0% | $47 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $168 | 0% | $168 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
Medium |
| X-Ray - Complete Intraoral Series | $155 | 0% | $155 |
Medium |
| X-Ray - Four Images, Bitewings | $82 | 0% | $82 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $27 | 0% | $27 |
Medium |
| X-Ray - Two Images, Bitewings | $55 | 0% | $55 |
Medium |
