| Dental Cleaning - Adult | $128 | 0% | $128 | 
Medium |
| Dental Cleaning - Child | $96 | 0% | $96 |
Medium |
| Dental Exam - Comprehensive | $195 | 0% | $195 |
Medium |
| Dental Exam - Periodic, Established Patient | $68 | 0% | $68 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $276 | 0% | $276 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $377 | 0% | $377 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $309 | 0% | $309 |
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 | $541 | 0% | $541 |
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 | $29 | 0% | $29 |
Medium |
| Maintenance Therapy - Periodontal | $193 | 0% | $193 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $333 | 0% | $333 |
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 | $109 | 0% | $109 |
Medium |
