| Dental Cleaning - Adult | $100 | 0% | $100 | 
Medium |
| Dental Cleaning - Child | $83 | 0% | $83 |
Medium |
| Dental Exam - Comprehensive | $84 | 0% | $84 |
Medium |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $194 | 0% | $194 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $307 | 0% | $307 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $242 | 0% | $242 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $173 | 0% | $173 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $184 | 0% | $184 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $299 | 0% | $299 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $205 | 0% | $205 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $242 | 0% | $242 |
Medium |
| Flouride - Topical Varnish Application | $46 | 0% | $46 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $84 | 0% | $84 |
Medium |
| Root Canal - Anterior Tooth | $814 | 0% | $814 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
Medium |
| X-Ray - Complete Intraoral Series | $142 | 0% | $142 |
Medium |
| X-Ray - Four Images, Bitewings | $72 | 0% | $72 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
Medium |
| X-Ray - Two Images, Bitewings | $49 | 0% | $49 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $131 | 0% | $131 |
Medium |
