| Dental Cleaning - Adult | $116 | 0% | $116 | 
Medium |
| Dental Exam - Comprehensive | $117 | 0% | $117 |
Medium |
| Dental Exam - Periodic, Established Patient | $61 | 0% | $61 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $243 | 0% | $243 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $386 | 0% | $386 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $309 | 0% | $309 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $204 | 0% | $204 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $243 | 0% | $243 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $309 | 0% | $309 |
Medium |
| Flouride - Topical Varnish Application | $27 | 0% | $27 |
Medium |
| Maintenance Therapy - Periodontal | $171 | 0% | $171 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | 0% | $105 |
Medium |
| X-Ray - Complete Intraoral Series | $176 | 0% | $176 |
Medium |
| X-Ray - Four Images, Bitewings | $95 | 0% | $95 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $43 | 0% | $43 |
Medium |
