| Dental Cleaning - Adult | $104 | 0% | $104 | 
Medium |
| Dental Cleaning - Child | $84 | 0% | $84 |
Medium |
| Dental Exam - Comprehensive | $92 | 0% | $92 |
Medium |
| Dental Exam - Periodic, Established Patient | $50 | 0% | $50 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $150 | 0% | $150 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $314 | 0% | $314 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $376 | 0% | $376 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $185 | 0% | $185 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $338 | 0% | $338 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $204 | 0% | $204 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $259 | 0% | $259 |
Medium |
| Fluoride - Topical Application | $44 | 0% | $44 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $246 | 0% | $246 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | 0% | $92 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | 0% | $184 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
Medium |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
Medium |
| X-Ray - Two Images, Bitewings | $51 | 0% | $51 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $133 | 0% | $133 |
Medium |
