| Dental Cleaning - Adult | $168 | 0% | $168 | 
Medium |
| Dental Cleaning - Child | $93 | 0% | $93 |
Medium |
| Dental Exam - Comprehensive | $137 | 0% | $137 |
Medium |
| Dental Exam - Periodic, Established Patient | $61 | 0% | $61 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $215 | 0% | $215 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | 0% | $326 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $273 | 0% | $273 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $187 | 0% | $187 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $215 | 0% | $215 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $460 | 0% | $460 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | 0% | $271 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $380 | 0% | $380 |
Medium |
| Flouride - Topical Varnish Application | $93 | 0% | $93 |
Medium |
| Fluoride - Topical Application | $55 | 0% | $55 |
Medium |
| Maintenance Therapy - Periodontal | $233 | 0% | $233 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $316 | 0% | $316 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $137 | 0% | $137 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $89 | 0% | $89 |
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 | $33 | 0% | $33 |
Medium |
| X-Ray - Complete Intraoral Series | $231 | 0% | $231 |
Medium |
| X-Ray - Four Images, Bitewings | $120 | 0% | $120 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $53 | 0% | $53 |
Medium |
| X-Ray - Two Images, Bitewings | $76 | 0% | $76 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $149 | 0% | $149 |
Medium |
