| Dental Cleaning - Adult | $112 | 0% | $112 | 
Medium |
| Dental Cleaning - Child | $89 | 0% | $89 |
Medium |
| Dental Exam - Comprehensive | $90 | 0% | $90 |
Medium |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $198 | 0% | $198 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | 0% | $342 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | 0% | $263 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $188 | 0% | $188 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $198 | 0% | $198 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $357 | 0% | $357 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $235 | 0% | $235 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
Medium |
| Flouride - Topical Varnish Application | $41 | 0% | $41 |
Medium |
| Maintenance Therapy - Periodontal | $165 | 0% | $165 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $284 | 0% | $284 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | 0% | $95 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | 0% | $59 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $240 | 0% | $240 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
Medium |
| X-Ray - Complete Intraoral Series | $158 | 0% | $158 |
Medium |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
Medium |
| X-Ray - Two Images, Bitewings | $58 | 0% | $58 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $131 | 0% | $131 |
Medium |
