| Dental Cleaning - Adult | $104 | 0% | $104 | 
Medium |
| Dental Cleaning - Child | $104 | 0% | $104 |
Medium |
| Dental Exam - Comprehensive | $207 | 0% | $207 |
Medium |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $143 | 0% | $143 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $221 | 0% | $221 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $176 | 0% | $176 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $164 | 0% | $164 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $278 | 0% | $278 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $198 | 0% | $198 |
Medium |
| Fluoride - Topical Application | $61 | 0% | $61 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $86 | 0% | $86 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $363 | 0% | $363 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
Medium |
| X-Ray - Complete Intraoral Series | $146 | 0% | $146 |
Medium |
| X-Ray - Four Images, Bitewings | $72 | 0% | $72 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
Medium |
