| Dental Cleaning - Adult | $89 | 0% | $89 | 
Medium |
| Dental Cleaning - Child | $68 | 0% | $68 |
Medium |
| Dental Exam - Comprehensive | $95 | 0% | $95 |
Medium |
| Dental Exam - Periodic, Established Patient | $44 | 0% | $44 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $188 | 0% | $188 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $313 | 0% | $313 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $261 | 0% | $261 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $165 | 0% | $165 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | 0% | $189 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $313 | 0% | $313 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $220 | 0% | $220 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $261 | 0% | $261 |
Medium |
| Flouride - Topical Varnish Application | $32 | 0% | $32 |
Medium |
| Maintenance Therapy - Periodontal | $132 | 0% | $132 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $82 | 0% | $82 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $51 | 0% | $51 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $174 | 0% | $174 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $25 | 0% | $25 |
Medium |
| X-Ray - Complete Intraoral Series | $131 | 0% | $131 |
Medium |
| X-Ray - Four Images, Bitewings | $63 | 0% | $63 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $29 | 0% | $29 |
Medium |
| X-Ray - Two Images, Bitewings | $45 | 0% | $45 |
Medium |
