| Dental Cleaning - Adult | $95 | 0% | $95 | 
Medium |
| Dental Cleaning - Child | $64 | 0% | $64 |
Medium |
| Dental Exam - Comprehensive | $112 | 0% | $112 |
Medium |
| Dental Exam - Periodic, Established Patient | $40 | 0% | $40 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $141 | 0% | $141 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $202 | 0% | $202 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $189 | 0% | $189 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $177 | 0% | $177 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | 0% | $189 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $172 | 0% | $172 |
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 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $48 | 0% | $48 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $21 | 0% | $21 |
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 |
| X-Ray - Whole Mouth from Outside Mouth | $111 | 0% | $111 |
Medium |
