| Dental Cleaning - Adult | $118 | 0% | $118 | 
Medium |
| Dental Cleaning - Child | $96 | 0% | $96 |
Medium |
| Dental Exam - Comprehensive | $133 | 0% | $133 |
Medium |
| Dental Exam - Periodic, Established Patient | $65 | 0% | $65 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $233 | 0% | $233 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $354 | 0% | $354 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $314 | 0% | $314 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $205 | 0% | $205 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $233 | 0% | $233 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $394 | 0% | $394 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $208 | 0% | $208 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $314 | 0% | $314 |
Medium |
| Flouride - Topical Varnish Application | $43 | 0% | $43 |
Medium |
| Fluoride - Topical Application | $55 | 0% | $55 |
Medium |
| Maintenance Therapy - Periodontal | $165 | 0% | $165 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $314 | 0% | $314 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $104 | 0% | $104 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | 0% | $71 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $247 | 0% | $247 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | 0% | $30 |
Medium |
| X-Ray - Complete Intraoral Series | $176 | 0% | $176 |
Medium |
| X-Ray - Four Images, Bitewings | $92 | 0% | $92 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | 0% | $46 |
Medium |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $168 | 0% | $168 |
Medium |
