| Dental Cleaning - Adult | $122 | 0% | $122 | 
Medium |
| Dental Cleaning - Child | $176 | 0% | $176 |
Medium |
| Dental Exam - Comprehensive | $93 | 0% | $93 |
Medium |
| Dental Exam - Periodic, Established Patient | $56 | 0% | $56 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $228 | 0% | $228 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $201 | 0% | $201 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $228 | 0% | $228 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $322 | 0% | $322 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $250 | 0% | $250 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $278 | 0% | $278 |
Medium |
| Flouride - Topical Varnish Application | $61 | 0% | $61 |
Medium |
| Maintenance Therapy - Periodontal | $160 | 0% | $160 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $191 | 0% | $191 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $55 | 0% | $55 |
Medium |
| X-Ray - Complete Intraoral Series | $154 | 0% | $154 |
Medium |
| X-Ray - Four Images, Bitewings | $83 | 0% | $83 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $71 | 0% | $71 |
Medium |
