| Dental Cleaning - Adult | $130 | 0% | $130 | 
Medium |
| Dental Cleaning - Child | $95 | 0% | $95 |
Medium |
| Dental Exam - Comprehensive | $110 | 0% | $110 |
Medium |
| Dental Exam - Periodic, Established Patient | $70 | 0% | $70 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $245 | 0% | $245 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $385 | 0% | $385 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $305 | 0% | $305 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $231 | 0% | $231 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $242 | 0% | $242 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $374 | 0% | $374 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $252 | 0% | $252 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $305 | 0% | $305 |
Medium |
| Fluoride - Topical Application | $54 | 0% | $54 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | 0% | $103 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $77 | 0% | $77 |
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 | $43 | 0% | $43 |
Medium |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $168 | 0% | $168 |
Medium |
