| Dental Cleaning - Adult | $129 | 0% | $129 | 
Medium |
| Dental Cleaning - Child | $96 | 0% | $96 |
Medium |
| Dental Exam - Comprehensive | $117 | 0% | $117 |
Medium |
| Dental Exam - Periodic, Established Patient | $68 | 0% | $68 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $315 | 0% | $315 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $377 | 0% | $377 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $416 | 0% | $416 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $221 | 0% | $221 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $236 | 0% | $236 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $377 | 0% | $377 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $267 | 0% | $267 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $309 | 0% | $309 |
Medium |
| Flouride - Topical Varnish Application | $30 | 0% | $30 |
Medium |
| Maintenance Therapy - Periodontal | $193 | 0% | $193 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $335 | 0% | $335 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $107 | 0% | $107 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $77 | 0% | $77 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | 0% | $38 |
Medium |
| X-Ray - Complete Intraoral Series | $208 | 0% | $208 |
Medium |
| X-Ray - Four Images, Bitewings | $91 | 0% | $91 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $45 | 0% | $45 |
Medium |
| X-Ray - Two Images, Bitewings | $67 | 0% | $67 |
Medium |
