| Dental Cleaning - Adult | $97 | 0% | $97 | 
Medium |
| Dental Cleaning - Child | $68 | 0% | $68 |
Medium |
| Dental Exam - Comprehensive | $89 | 0% | $89 |
Medium |
| Dental Exam - Periodic, Established Patient | $48 | 0% | $48 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $378 | 0% | $378 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $147 | 0% | $147 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $173 | 0% | $173 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $173 | 0% | $173 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $194 | 0% | $194 |
Medium |
| Flouride - Topical Varnish Application | $47 | 0% | $47 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $74 | 0% | $74 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $22 | 0% | $22 |
Medium |
| X-Ray - Complete Intraoral Series | $137 | 0% | $137 |
Medium |
| X-Ray - Four Images, Bitewings | $74 | 0% | $74 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $28 | 0% | $28 |
Medium |
| X-Ray - Two Images, Bitewings | $53 | 0% | $53 |
Medium |
