| Dental Cleaning - Adult | $146 | 0% | $146 | 
Medium |
| Dental Cleaning - Child | $118 | 0% | $118 |
Medium |
| Dental Exam - Comprehensive | $161 | 0% | $161 |
Medium |
| Dental Exam - Periodic, Established Patient | $68 | 0% | $68 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $258 | 0% | $258 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $515 | 0% | $515 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $392 | 0% | $392 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $246 | 0% | $246 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $258 | 0% | $258 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $540 | 0% | $540 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $392 | 0% | $392 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $392 | 0% | $392 |
Medium |
| Flouride - Topical Varnish Application | $41 | 0% | $41 |
Medium |
| Maintenance Therapy - Periodontal | $165 | 0% | $165 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $379 | 0% | $379 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | 0% | $103 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | 0% | $71 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $265 | 0% | $265 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
Medium |
| X-Ray - Complete Intraoral Series | $219 | 0% | $219 |
Medium |
| X-Ray - Four Images, Bitewings | $95 | 0% | $95 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $57 | 0% | $57 |
Medium |
| X-Ray - Two Images, Bitewings | $91 | 0% | $91 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $171 | 0% | $171 |
Medium |
