| Dental Cleaning - Adult | $110 | 0% | $110 | 
Medium |
| Dental Cleaning - Child | $89 | 0% | $89 |
Medium |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $209 | 0% | $209 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $209 | 0% | $209 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $209 | 0% | $209 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $324 | 0% | $324 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $269 | 0% | $269 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $269 | 0% | $269 |
Medium |
| Flouride - Topical Varnish Application | $58 | 0% | $58 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | 0% | $100 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
Medium |
| X-Ray - Four Images, Bitewings | $104 | 0% | $104 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $65 | 0% | $65 |
Medium |
| X-Ray - Two Images, Bitewings | $93 | 0% | $93 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $158 | 0% | $158 |
Medium |
