| Dental Cleaning - Adult | $160 | 0% | $160 | 
Medium |
| Dental Cleaning - Child | $117 | 0% | $117 |
Medium |
| Dental Exam - Comprehensive | $86 | 0% | $86 |
Medium |
| Dental Exam - Periodic, Established Patient | $66 | 0% | $66 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $292 | 0% | $292 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $421 | 0% | $421 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $366 | 0% | $366 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $250 | 0% | $250 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $292 | 0% | $292 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $421 | 0% | $421 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $300 | 0% | $300 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $366 | 0% | $366 |
Medium |
| Maintenance Therapy - Periodontal | $187 | 0% | $187 |
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 | $96 | 0% | $96 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $397 | 0% | $397 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $41 | 0% | $41 |
Medium |
| X-Ray - Complete Intraoral Series | $315 | 0% | $315 |
Medium |
| X-Ray - Four Images, Bitewings | $102 | 0% | $102 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $51 | 0% | $51 |
Medium |
| X-Ray - Two Images, Bitewings | $87 | 0% | $87 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $223 | 0% | $223 |
Medium |
