| Dental Cleaning - Adult | $116 | 0% | $116 | 
Medium |
| Dental Cleaning - Child | $95 | 0% | $95 |
Medium |
| Dental Exam - Comprehensive | $108 | 0% | $108 |
Medium |
| Dental Exam - Periodic, Established Patient | $51 | 0% | $51 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $223 | 0% | $223 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $360 | 0% | $360 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $282 | 0% | $282 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $209 | 0% | $209 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $223 | 0% | $223 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $373 | 0% | $373 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $240 | 0% | $240 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $282 | 0% | $282 |
Medium |
| Flouride - Topical Varnish Application | $37 | 0% | $37 |
Medium |
| Fluoride - Topical Application | $37 | 0% | $37 |
Medium |
| Maintenance Therapy - Periodontal | $177 | 0% | $177 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $318 | 0% | $318 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | 0% | $105 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | 0% | $68 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $261 | 0% | $261 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $43 | 0% | $43 |
Medium |
| X-Ray - Complete Intraoral Series | $158 | 0% | $158 |
Medium |
| X-Ray - Four Images, Bitewings | $81 | 0% | $81 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $45 | 0% | $45 |
Medium |
| X-Ray - Two Images, Bitewings | $66 | 0% | $66 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $158 | 0% | $158 |
Medium |
