| Dental Cleaning - Adult | $137 | 0% | $137 | 
Medium |
| Dental Cleaning - Child | $118 | 0% | $118 |
Medium |
| Dental Exam - Comprehensive | $104 | 0% | $104 |
Medium |
| Dental Exam - Periodic, Established Patient | $72 | 0% | $72 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $202 | 0% | $202 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $301 | 0% | $301 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $231 | 0% | $231 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $202 | 0% | $202 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $624 | 0% | $624 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $508 | 0% | $508 |
Medium |
| Fluoride - Topical Application | $56 | 0% | $56 |
Medium |
| Maintenance Therapy - Periodontal | $171 | 0% | $171 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $87 | 0% | $87 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $70 | 0% | $70 |
Medium |
| X-Ray - Complete Intraoral Series | $158 | 0% | $158 |
Medium |
| X-Ray - Four Images, Bitewings | $79 | 0% | $79 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $33 | 0% | $33 |
Medium |
| X-Ray - Two Images, Bitewings | $58 | 0% | $58 |
Medium |
