| Dental Cleaning - Adult | $116 | 0% | $116 | 
Medium |
| Dental Cleaning - Child | $179 | 0% | $179 |
Medium |
| Dental Exam - Comprehensive | $105 | 0% | $105 |
Medium |
| Dental Exam - Periodic, Established Patient | $57 | 0% | $57 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $310 | 0% | $310 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $525 | 0% | $525 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $252 | 0% | $252 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $228 | 0% | $228 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $620 | 0% | $620 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $420 | 0% | $420 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | 0% | $105 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | 0% | $38 |
Medium |
| X-Ray - Complete Intraoral Series | $305 | 0% | $305 |
Medium |
| X-Ray - Four Images, Bitewings | $89 | 0% | $89 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
Medium |
