| Dental Cleaning - Adult | $124 | 0% | $124 | 
Medium |
| Dental Cleaning - Child | $134 | 0% | $134 |
Medium |
| Dental Exam - Comprehensive | $82 | 0% | $82 |
Medium |
| Dental Exam - Periodic, Established Patient | $46 | 0% | $46 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $265 | 0% | $265 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $427 | 0% | $427 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $185 | 0% | $185 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $172 | 0% | $172 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $207 | 0% | $207 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $238 | 0% | $238 |
Medium |
| Flouride - Topical Varnish Application | $42 | 0% | $42 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $256 | 0% | $256 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $131 | 0% | $131 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $242 | 0% | $242 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $22 | 0% | $22 |
Medium |
| X-Ray - Complete Intraoral Series | $176 | 0% | $176 |
Medium |
| X-Ray - Four Images, Bitewings | $78 | 0% | $78 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
Medium |
| X-Ray - Two Images, Bitewings | $62 | 0% | $62 |
Medium |
