| Dental Cleaning - Adult | $155 | 0% | $155 | 
Medium |
| Dental Cleaning - Child | $86 | 0% | $86 |
Medium |
| Dental Exam - Comprehensive | $161 | 0% | $161 |
Medium |
| Dental Exam - Periodic, Established Patient | $74 | 0% | $74 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $185 | 0% | $185 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $257 | 0% | $257 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $235 | 0% | $235 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $200 | 0% | $200 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $315 | 0% | $315 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $260 | 0% | $260 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $257 | 0% | $257 |
Medium |
| Fluoride - Topical Application | $63 | 0% | $63 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | 0% | $105 |
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 | $42 | 0% | $42 |
Medium |
| X-Ray - Complete Intraoral Series | $168 | 0% | $168 |
Medium |
| X-Ray - Four Images, Bitewings | $86 | 0% | $86 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
Medium |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
Medium |
