| Dental Cleaning - Adult | $113 | 0% | $113 | 
Medium |
| Dental Cleaning - Child | $88 | 0% | $88 |
Medium |
| Dental Exam - Comprehensive | $101 | 0% | $101 |
Medium |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $363 | 0% | $363 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $197 | 0% | $197 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $218 | 0% | $218 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $363 | 0% | $363 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $285 | 0% | $285 |
Medium |
| Fluoride - Topical Application | $53 | 0% | $53 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $96 | 0% | $96 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $40 | 0% | $40 |
Medium |
| X-Ray - Complete Intraoral Series | $247 | 0% | $247 |
Medium |
| X-Ray - Four Images, Bitewings | $89 | 0% | $89 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
Medium |
| X-Ray - Two Images, Bitewings | $90 | 0% | $90 |
Medium |
