| Dental Cleaning - Adult | $129 | 0% | $129 | 
Medium |
| Dental Cleaning - Child | $88 | 0% | $88 |
Medium |
| Dental Exam - Comprehensive | $124 | 0% | $124 |
Medium |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $237 | 0% | $237 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $352 | 0% | $352 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $291 | 0% | $291 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $203 | 0% | $203 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $237 | 0% | $237 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $461 | 0% | $461 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $335 | 0% | $335 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $319 | 0% | $319 |
Medium |
| Flouride - Topical Varnish Application | $49 | 0% | $49 |
Medium |
| Fluoride - Topical Application | $63 | 0% | $63 |
Medium |
| Maintenance Therapy - Periodontal | $161 | 0% | $161 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $329 | 0% | $329 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $109 | 0% | $109 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $76 | 0% | $76 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $256 | 0% | $256 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $44 | 0% | $44 |
Medium |
| X-Ray - Complete Intraoral Series | $208 | 0% | $208 |
Medium |
| X-Ray - Four Images, Bitewings | $89 | 0% | $89 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $44 | 0% | $44 |
Medium |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $135 | 0% | $135 |
Medium |
