| Dental Cleaning - Adult | $116 | 0% | $116 | 
Medium |
| Dental Cleaning - Child | $88 | 0% | $88 |
Medium |
| Dental Exam - Comprehensive | $131 | 0% | $131 |
Medium |
| Dental Exam - Periodic, Established Patient | $44 | 0% | $44 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $201 | 0% | $201 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $368 | 0% | $368 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $268 | 0% | $268 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $236 | 0% | $236 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $236 | 0% | $236 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $368 | 0% | $368 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $289 | 0% | $289 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $289 | 0% | $289 |
Medium |
| Flouride - Topical Varnish Application | $51 | 0% | $51 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $98 | 0% | $98 |
Medium |
| X-Ray - Complete Intraoral Series | $244 | 0% | $244 |
Medium |
| X-Ray - Four Images, Bitewings | $79 | 0% | $79 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $71 | 0% | $71 |
Medium |
| X-Ray - Two Images, Bitewings | $44 | 0% | $44 |
Medium |
