| Dental Cleaning - Adult | $103 | 0% | $103 | 
Medium |
| Dental Cleaning - Child | $83 | 0% | $83 |
Medium |
| Dental Exam - Comprehensive | $89 | 0% | $89 |
Medium |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $186 | 0% | $186 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $259 | 0% | $259 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $261 | 0% | $261 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $186 | 0% | $186 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $674 | 0% | $674 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $198 | 0% | $198 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $259 | 0% | $259 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $87 | 0% | $87 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
Medium |
| X-Ray - Four Images, Bitewings | $70 | 0% | $70 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
Medium |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
Medium |
