| Dental Cleaning - Adult | $131 | 0% | $131 | 
Medium |
| Dental Cleaning - Child | $102 | 0% | $102 |
Medium |
| Dental Exam - Comprehensive | $78 | 0% | $78 |
Medium |
| Dental Exam - Periodic, Established Patient | $78 | 0% | $78 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $222 | 0% | $222 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $387 | 0% | $387 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $345 | 0% | $345 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $263 | 0% | $263 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $261 | 0% | $261 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $338 | 0% | $338 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $345 | 0% | $345 |
Medium |
| Flouride - Topical Varnish Application | $65 | 0% | $65 |
Medium |
| Fluoride - Topical Application | $61 | 0% | $61 |
Medium |
| Maintenance Therapy - Periodontal | $177 | 0% | $177 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $404 | 0% | $404 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $126 | 0% | $126 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $81 | 0% | $81 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $47 | 0% | $47 |
Medium |
| X-Ray - Complete Intraoral Series | $198 | 0% | $198 |
Medium |
| X-Ray - Four Images, Bitewings | $147 | 0% | $147 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $50 | 0% | $50 |
Medium |
| X-Ray - Two Images, Bitewings | $97 | 0% | $97 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $186 | 0% | $186 |
Medium |
