| Dental Cleaning - Adult | $95 | 0% | $95 | 
Medium |
| Dental Cleaning - Child | $76 | 0% | $76 |
Medium |
| Dental Exam - Comprehensive | $82 | 0% | $82 |
Medium |
| Dental Exam - Periodic, Established Patient | $39 | 0% | $39 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $116 | 0% | $116 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $263 | 0% | $263 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $161 | 0% | $161 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $161 | 0% | $161 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
Medium |
| Fluoride - Topical Application | $34 | 0% | $34 |
Medium |
| Maintenance Therapy - Periodontal | $142 | 0% | $142 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $71 | 0% | $71 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $42 | 0% | $42 |
Medium |
| X-Ray - Complete Intraoral Series | $126 | 0% | $126 |
Medium |
| X-Ray - Four Images, Bitewings | $60 | 0% | $60 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $30 | 0% | $30 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $111 | 0% | $111 |
Medium |
