| Dental Cleaning - Adult | $87 | 0% | $87 | 
Medium |
| Dental Cleaning - Child | $69 | 0% | $69 |
Medium |
| Dental Exam - Comprehensive | $120 | 0% | $120 |
Medium |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $144 | 0% | $144 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $441 | 0% | $441 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $205 | 0% | $205 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $173 | 0% | $173 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $147 | 0% | $147 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $294 | 0% | $294 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $410 | 0% | $410 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $205 | 0% | $205 |
Medium |
| Flouride - Topical Varnish Application | $36 | 0% | $36 |
Medium |
| Maintenance Therapy - Periodontal | $227 | 0% | $227 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $60 | 0% | $60 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $50 | 0% | $50 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
Medium |
| X-Ray - Complete Intraoral Series | $126 | 0% | $126 |
Medium |
| X-Ray - Four Images, Bitewings | $60 | 0% | $60 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
Medium |
| X-Ray - Two Images, Bitewings | $60 | 0% | $60 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $158 | 0% | $158 |
Medium |
