| Dental Cleaning - Adult | $137 | 0% | $137 | 
Medium |
| Dental Cleaning - Child | $116 | 0% | $116 |
Medium |
| Dental Exam - Comprehensive | $137 | 0% | $137 |
Medium |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $282 | 0% | $282 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $383 | 0% | $383 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $331 | 0% | $331 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $278 | 0% | $278 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $278 | 0% | $278 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $389 | 0% | $389 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $331 | 0% | $331 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $331 | 0% | $331 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $271 | 0% | $271 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
Medium |
| X-Ray - Complete Intraoral Series | $189 | 0% | $189 |
Medium |
| X-Ray - Four Images, Bitewings | $89 | 0% | $89 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $43 | 0% | $43 |
Medium |
| X-Ray - Two Images, Bitewings | $70 | 0% | $70 |
Medium |
