| Dental Cleaning - Adult | $133 | 0% | $133 | 
Medium |
| Dental Cleaning - Child | $114 | 0% | $114 |
Medium |
| Dental Exam - Comprehensive | $117 | 0% | $117 |
Medium |
| Dental Exam - Periodic, Established Patient | $71 | 0% | $71 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $242 | 0% | $242 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $440 | 0% | $440 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $338 | 0% | $338 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $212 | 0% | $212 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $242 | 0% | $242 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $440 | 0% | $440 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $258 | 0% | $258 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $338 | 0% | $338 |
Medium |
| Fluoride - Topical Application | $58 | 0% | $58 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $119 | 0% | $119 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $83 | 0% | $83 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $257 | 0% | $257 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
Medium |
| X-Ray - Complete Intraoral Series | $183 | 0% | $183 |
Medium |
| X-Ray - Four Images, Bitewings | $96 | 0% | $96 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $43 | 0% | $43 |
Medium |
| X-Ray - Two Images, Bitewings | $68 | 0% | $68 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $176 | 0% | $176 |
Medium |
