| Dental Cleaning - Adult | $102 | 0% | $102 | 
Medium |
| Dental Cleaning - Child | $79 | 0% | $79 |
Medium |
| Dental Exam - Comprehensive | $88 | 0% | $88 |
Medium |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $127 | 0% | $127 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $299 | 0% | $299 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $168 | 0% | $168 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $290 | 0% | $290 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $279 | 0% | $279 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $299 | 0% | $299 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $336 | 0% | $336 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $370 | 0% | $370 |
Medium |
| Flouride - Topical Varnish Application | $47 | 0% | $47 |
Medium |
| Fluoride - Topical Application | $27 | 0% | $27 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $86 | 0% | $86 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $56 | 0% | $56 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $23 | 0% | $23 |
Medium |
| X-Ray - Complete Intraoral Series | $143 | 0% | $143 |
Medium |
| X-Ray - Four Images, Bitewings | $69 | 0% | $69 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $21 | 0% | $21 |
Medium |
| X-Ray - Two Images, Bitewings | $49 | 0% | $49 |
Medium |
