| Dental Cleaning - Adult | $155 | 0% | $155 | 
Medium |
| Dental Cleaning - Child | $118 | 0% | $118 |
Medium |
| Dental Exam - Comprehensive | $163 | 0% | $163 |
Medium |
| Dental Exam - Periodic, Established Patient | $76 | 0% | $76 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $185 | 0% | $185 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $331 | 0% | $331 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $256 | 0% | $256 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $208 | 0% | $208 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $200 | 0% | $200 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $238 | 0% | $238 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $441 | 0% | $441 |
Medium |
| Fluoride - Topical Application | $71 | 0% | $71 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $310 | 0% | $310 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $148 | 0% | $148 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $67 | 0% | $67 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $44 | 0% | $44 |
Medium |
| X-Ray - Complete Intraoral Series | $171 | 0% | $171 |
Medium |
| X-Ray - Four Images, Bitewings | $88 | 0% | $88 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $44 | 0% | $44 |
Medium |
