| Dental Cleaning - Adult | $106 | 0% | $106 | 
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 | $231 | 0% | $231 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $277 | 0% | $277 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $196 | 0% | $196 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $231 | 0% | $231 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $380 | 0% | $380 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $281 | 0% | $281 |
Medium |
| Flouride - Topical Varnish Application | $42 | 0% | $42 |
Medium |
| Fluoride - Topical Application | $40 | 0% | $40 |
Medium |
| Maintenance Therapy - Periodontal | $165 | 0% | $165 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | 0% | $100 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $57 | 0% | $57 |
Medium |
| X-Ray - Complete Intraoral Series | $155 | 0% | $155 |
Medium |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $48 | 0% | $48 |
Medium |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $126 | 0% | $126 |
Medium |
