| Dental Cleaning - Adult | $98 | 0% | $98 | 
Medium |
| Dental Cleaning - Child | $78 | 0% | $78 |
Medium |
| Dental Exam - Comprehensive | $83 | 0% | $83 |
Medium |
| Dental Exam - Periodic, Established Patient | $46 | 0% | $46 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $166 | 0% | $166 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $275 | 0% | $275 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $221 | 0% | $221 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $145 | 0% | $145 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $166 | 0% | $166 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $275 | 0% | $275 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $181 | 0% | $181 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $221 | 0% | $221 |
Medium |
| Flouride - Topical Varnish Application | $45 | 0% | $45 |
Medium |
| Maintenance Therapy - Periodontal | $144 | 0% | $144 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $254 | 0% | $254 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $80 | 0% | $80 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $57 | 0% | $57 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $172 | 0% | $172 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $24 | 0% | $24 |
Medium |
| X-Ray - Complete Intraoral Series | $140 | 0% | $140 |
Medium |
| X-Ray - Four Images, Bitewings | $65 | 0% | $65 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $30 | 0% | $30 |
Medium |
| X-Ray - Two Images, Bitewings | $47 | 0% | $47 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $126 | 0% | $126 |
Medium |
