| Dental Cleaning - Adult | $95 | 0% | $95 | 
Medium |
| Dental Cleaning - Child | $64 | 0% | $64 |
Medium |
| Dental Exam - Comprehensive | $143 | 0% | $143 |
Medium |
| Dental Exam - Periodic, Established Patient | $40 | 0% | $40 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | 0% | $189 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $215 | 0% | $215 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $189 | 0% | $189 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $260 | 0% | $260 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $235 | 0% | $235 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $464 | 0% | $464 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $166 | 0% | $166 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $376 | 0% | $376 |
Medium |
| Flouride - Topical Varnish Application | $40 | 0% | $40 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $68 | 0% | $68 |
Medium |
| X-Ray - Four Images, Bitewings | $64 | 0% | $64 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $26 | 0% | $26 |
Medium |
| X-Ray - Two Images, Bitewings | $41 | 0% | $41 |
Medium |
