| Dental Cleaning - Adult | $112 | 0% | $112 | 
Medium |
| Dental Cleaning - Child | $121 | 0% | $121 |
Medium |
| Dental Exam - Comprehensive | $100 | 0% | $100 |
Medium |
| Dental Exam - Periodic, Established Patient | $51 | 0% | $51 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $252 | 0% | $252 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $179 | 0% | $179 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $179 | 0% | $179 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $466 | 0% | $466 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $252 | 0% | $252 |
Medium |
| Fluoride - Topical Application | $57 | 0% | $57 |
Medium |
| Maintenance Therapy - Periodontal | $153 | 0% | $153 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $289 | 0% | $289 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | 0% | $88 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
Medium |
| X-Ray - Complete Intraoral Series | $152 | 0% | $152 |
Medium |
| X-Ray - Four Images, Bitewings | $79 | 0% | $79 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
Medium |
| X-Ray - Two Images, Bitewings | $107 | 0% | $107 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $152 | 0% | $152 |
Medium |
