| Dental Cleaning - Adult | $152 | 0% | $152 | 
Medium |
| Dental Cleaning - Child | $116 | 0% | $116 |
Medium |
| Dental Exam - Comprehensive | $168 | 0% | $168 |
Medium |
| Dental Exam - Periodic, Established Patient | $79 | 0% | $79 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $326 | 0% | $326 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $341 | 0% | $341 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $420 | 0% | $420 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $347 | 0% | $347 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $357 | 0% | $357 |
Medium |
| Flouride - Topical Varnish Application | $79 | 0% | $79 |
Medium |
| Fluoride - Topical Application | $79 | 0% | $79 |
Medium |
| Maintenance Therapy - Periodontal | $247 | 0% | $247 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $431 | 0% | $431 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $137 | 0% | $137 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $89 | 0% | $89 |
Medium |
| X-Ray - Complete Intraoral Series | $226 | 0% | $226 |
Medium |
| X-Ray - Four Images, Bitewings | $121 | 0% | $121 |
Medium |
| X-Ray - Two Images, Bitewings | $79 | 0% | $79 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $205 | 0% | $205 |
Medium |
