| Dental Cleaning - Adult | $124 | 0% | $124 | 
Medium |
| Dental Cleaning - Child | $69 | 0% | $69 |
Medium |
| Dental Exam - Comprehensive | $142 | 0% | $142 |
Medium |
| Dental Exam - Periodic, Established Patient | $45 | 0% | $45 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $236 | 0% | $236 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $604 | 0% | $604 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $446 | 0% | $446 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $236 | 0% | $236 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $236 | 0% | $236 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $551 | 0% | $551 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $394 | 0% | $394 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $446 | 0% | $446 |
Medium |
| Fluoride - Topical Application | $27 | 0% | $27 |
Medium |
| Maintenance Therapy - Periodontal | $152 | 0% | $152 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $63 | 0% | $63 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $21 | 0% | $21 |
Medium |
| X-Ray - Complete Intraoral Series | $156 | 0% | $156 |
Medium |
| X-Ray - Four Images, Bitewings | $72 | 0% | $72 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $22 | 0% | $22 |
Medium |
| X-Ray - Two Images, Bitewings | $58 | 0% | $58 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $146 | 0% | $146 |
Medium |
