| Dental Cleaning - Adult | $158 | 0% | $158 | 
Medium |
| Dental Cleaning - Child | $137 | 0% | $137 |
Medium |
| Dental Exam - Comprehensive | $158 | 0% | $158 |
Medium |
| Dental Exam - Periodic, Established Patient | $95 | 0% | $95 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $210 | 0% | $210 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $420 | 0% | $420 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $368 | 0% | $368 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $210 | 0% | $210 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $236 | 0% | $236 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $394 | 0% | $394 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $368 | 0% | $368 |
Medium |
| Fluoride - Topical Application | $63 | 0% | $63 |
Medium |
| Maintenance Therapy - Periodontal | $210 | 0% | $210 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $131 | 0% | $131 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
Medium |
| X-Ray - Four Images, Bitewings | $137 | 0% | $137 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
Medium |
| X-Ray - Two Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $184 | 0% | $184 |
Medium |
