| Dental Cleaning - Adult | $121 | 0% | $121 | 
Medium |
| Dental Cleaning - Child | $87 | 0% | $87 |
Medium |
| Dental Exam - Comprehensive | $113 | 0% | $113 |
Medium |
| Dental Exam - Periodic, Established Patient | $65 | 0% | $65 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $176 | 0% | $176 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $214 | 0% | $214 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $194 | 0% | $194 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $275 | 0% | $275 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $458 | 0% | $458 |
Medium |
| Flouride - Topical Varnish Application | $68 | 0% | $68 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | 0% | $101 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | 0% | $71 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
Medium |
| X-Ray - Complete Intraoral Series | $184 | 0% | $184 |
Medium |
| X-Ray - Four Images, Bitewings | $89 | 0% | $89 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $55 | 0% | $55 |
Medium |
| X-Ray - Two Images, Bitewings | $68 | 0% | $68 |
Medium |
