| Dental Cleaning - Adult | $206 | 0% | $206 | 
Medium |
| Dental Cleaning - Child | $164 | 0% | $164 |
Medium |
| Dental Exam - Periodic, Established Patient | $80 | 0% | $80 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $389 | 0% | $389 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $578 | 0% | $578 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $473 | 0% | $473 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $683 | 0% | $683 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
Medium |
| Fluoride - Topical Application | $78 | 0% | $78 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | 0% | $95 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $55 | 0% | $55 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $55 | 0% | $55 |
Medium |
| X-Ray - Two Images, Bitewings | $88 | 0% | $88 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $242 | 0% | $242 |
Medium |
