| Dental Cleaning - Adult | $131 | 0% | $131 | 
Medium |
| Dental Cleaning - Child | $99 | 0% | $99 |
Medium |
| Dental Exam - Periodic, Established Patient | $70 | 0% | $70 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $194 | 0% | $194 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $521 | 0% | $521 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $191 | 0% | $191 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $191 | 0% | $191 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $307 | 0% | $307 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $202 | 0% | $202 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $260 | 0% | $260 |
Medium |
| Flouride - Topical Varnish Application | $55 | 0% | $55 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $109 | 0% | $109 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $78 | 0% | $78 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $48 | 0% | $48 |
Medium |
| X-Ray - Complete Intraoral Series | $179 | 0% | $179 |
Medium |
| X-Ray - Four Images, Bitewings | $88 | 0% | $88 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $48 | 0% | $48 |
Medium |
