| Dental Cleaning - Adult | $121 | 0% | $121 | 
Medium |
| Dental Cleaning - Child | $84 | 0% | $84 |
Medium |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $244 | 0% | $244 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $373 | 0% | $373 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $326 | 0% | $326 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $221 | 0% | $221 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $268 | 0% | $268 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $373 | 0% | $373 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $273 | 0% | $273 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $297 | 0% | $297 |
Medium |
| Flouride - Topical Varnish Application | $42 | 0% | $42 |
Medium |
| Maintenance Therapy - Periodontal | $142 | 0% | $142 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $131 | 0% | $131 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $56 | 0% | $56 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $44 | 0% | $44 |
Medium |
| X-Ray - Complete Intraoral Series | $158 | 0% | $158 |
Medium |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
Medium |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
Medium |
