| Dental Cleaning - Adult | $109 | 0% | $109 | 
Medium |
| Dental Cleaning - Child | $87 | 0% | $87 |
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 | $194 | 0% | $194 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $347 | 0% | $347 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $261 | 0% | $261 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $160 | 0% | $160 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $194 | 0% | $194 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $354 | 0% | $354 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $206 | 0% | $206 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $261 | 0% | $261 |
Medium |
| Flouride - Topical Varnish Application | $41 | 0% | $41 |
Medium |
| Fluoride - Topical Application | $36 | 0% | $36 |
Medium |
| Maintenance Therapy - Periodontal | $151 | 0% | $151 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $296 | 0% | $296 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $118 | 0% | $118 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $62 | 0% | $62 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $177 | 0% | $177 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
Medium |
| X-Ray - Complete Intraoral Series | $215 | 0% | $215 |
Medium |
| X-Ray - Four Images, Bitewings | $72 | 0% | $72 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $61 | 0% | $61 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $143 | 0% | $143 |
Medium |
