| Dental Cleaning - Adult | $121 | 0% | $121 | 
Medium |
| Dental Cleaning - Child | $141 | 0% | $141 |
Medium |
| Dental Exam - Comprehensive | $77 | 0% | $77 |
Medium |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $166 | 0% | $166 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $226 | 0% | $226 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $179 | 0% | $179 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $323 | 0% | $323 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $187 | 0% | $187 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $189 | 0% | $189 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $390 | 0% | $390 |
Medium |
| Flouride - Topical Varnish Application | $42 | 0% | $42 |
Medium |
| Fluoride - Topical Application | $84 | 0% | $84 |
Medium |
| Maintenance Therapy - Periodontal | $131 | 0% | $131 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | 0% | $88 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $17 | 0% | $17 |
Medium |
| X-Ray - Complete Intraoral Series | $139 | 0% | $139 |
Medium |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $28 | 0% | $28 |
Medium |
| X-Ray - Two Images, Bitewings | $43 | 0% | $43 |
Medium |
