| Dental Cleaning - Adult | $102 | 0% | $102 | 
Medium |
| Dental Cleaning - Child | $82 | 0% | $82 |
Medium |
| Dental Exam - Comprehensive | $179 | 0% | $179 |
Medium |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $334 | 0% | $334 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $515 | 0% | $515 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $168 | 0% | $168 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $188 | 0% | $188 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $334 | 0% | $334 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $211 | 0% | $211 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $386 | 0% | $386 |
Medium |
| Flouride - Topical Varnish Application | $69 | 0% | $69 |
Medium |
| Fluoride - Topical Application | $45 | 0% | $45 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $86 | 0% | $86 |
Medium |
| X-Ray - Four Images, Bitewings | $69 | 0% | $69 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $33 | 0% | $33 |
Medium |
| X-Ray - Two Images, Bitewings | $49 | 0% | $49 |
Medium |
