| Dental Cleaning - Adult | $131 | 0% | $131 | 
Medium |
| Dental Cleaning - Child | $200 | 0% | $200 |
Medium |
| Dental Exam - Periodic, Established Patient | $70 | 0% | $70 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $389 | 0% | $389 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $521 | 0% | $521 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $194 | 0% | $194 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $308 | 0% | $308 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $202 | 0% | $202 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $521 | 0% | $521 |
Medium |
| Flouride - Topical Varnish Application | $55 | 0% | $55 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $114 | 0% | $114 |
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 - Four Images, Bitewings | $88 | 0% | $88 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $48 | 0% | $48 |
Medium |
