| Dental Cleaning - Adult | $134 | 0% | $134 | 
Medium |
| Dental Cleaning - Child | $100 | 0% | $100 |
Medium |
| Dental Exam - Comprehensive | $134 | 0% | $134 |
Medium |
| Dental Exam - Periodic, Established Patient | $66 | 0% | $66 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $273 | 0% | $273 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $418 | 0% | $418 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $349 | 0% | $349 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $242 | 0% | $242 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $273 | 0% | $273 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $418 | 0% | $418 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $289 | 0% | $289 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $349 | 0% | $349 |
Medium |
| Flouride - Topical Varnish Application | $77 | 0% | $77 |
Medium |
| Fluoride - Topical Application | $51 | 0% | $51 |
Medium |
| Maintenance Therapy - Periodontal | $209 | 0% | $209 |
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 | $75 | 0% | $75 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $273 | 0% | $273 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $45 | 0% | $45 |
Medium |
| X-Ray - Complete Intraoral Series | $225 | 0% | $225 |
Medium |
| X-Ray - Four Images, Bitewings | $92 | 0% | $92 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $45 | 0% | $45 |
Medium |
| X-Ray - Two Images, Bitewings | $66 | 0% | $66 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $163 | 0% | $163 |
Medium |
