| Dental Cleaning - Adult | $95 | 0% | $95 | 
Medium |
| Dental Cleaning - Child | $68 | 0% | $68 |
Medium |
| Dental Exam - Comprehensive | $101 | 0% | $101 |
Medium |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $154 | 0% | $154 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $245 | 0% | $245 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $152 | 0% | $152 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $145 | 0% | $145 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $154 | 0% | $154 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $176 | 0% | $176 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $246 | 0% | $246 |
Medium |
| Fluoride - Topical Application | $39 | 0% | $39 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $315 | 0% | $315 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | 0% | $101 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $195 | 0% | $195 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $18 | 0% | $18 |
Medium |
| X-Ray - Complete Intraoral Series | $137 | 0% | $137 |
Medium |
| X-Ray - Four Images, Bitewings | $61 | 0% | $61 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $28 | 0% | $28 |
Medium |
| X-Ray - Two Images, Bitewings | $40 | 0% | $40 |
Medium |
