| Dental Cleaning - Adult | $116 | 0% | $116 | 
Medium |
| Dental Cleaning - Child | $89 | 0% | $89 |
Medium |
| Dental Exam - Comprehensive | $116 | 0% | $116 |
Medium |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $273 | 0% | $273 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $289 | 0% | $289 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $221 | 0% | $221 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $242 | 0% | $242 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $357 | 0% | $357 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $289 | 0% | $289 |
Medium |
| Flouride - Topical Varnish Application | $95 | 0% | $95 |
Medium |
| Fluoride - Topical Application | $47 | 0% | $47 |
Medium |
| Maintenance Therapy - Periodontal | $173 | 0% | $173 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | 0% | $95 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $63 | 0% | $63 |
Medium |
| X-Ray - Complete Intraoral Series | $163 | 0% | $163 |
Medium |
| X-Ray - Four Images, Bitewings | $79 | 0% | $79 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $74 | 0% | $74 |
Medium |
| X-Ray - Two Images, Bitewings | $58 | 0% | $58 |
Medium |
