| Dental Cleaning - Adult | $121 | 0% | $121 | 
Medium |
| Dental Cleaning - Child | $92 | 0% | $92 |
Medium |
| Dental Exam - Comprehensive | $119 | 0% | $119 |
Medium |
| Dental Exam - Periodic, Established Patient | $68 | 0% | $68 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $243 | 0% | $243 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $385 | 0% | $385 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $315 | 0% | $315 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $249 | 0% | $249 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $273 | 0% | $273 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $315 | 0% | $315 |
Medium |
| Flouride - Topical Varnish Application | $58 | 0% | $58 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $77 | 0% | $77 |
Medium |
| X-Ray - Complete Intraoral Series | $177 | 0% | $177 |
Medium |
| X-Ray - Four Images, Bitewings | $89 | 0% | $89 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
Medium |
