| Dental Cleaning - Adult | $114 | 0% | $114 | 
Medium |
| Dental Cleaning - Child | $95 | 0% | $95 |
Medium |
| Dental Exam - Comprehensive | $125 | 0% | $125 |
Medium |
| Dental Exam - Periodic, Established Patient | $51 | 0% | $51 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $292 | 0% | $292 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $187 | 0% | $187 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $347 | 0% | $347 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $196 | 0% | $196 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $358 | 0% | $358 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $222 | 0% | $222 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $275 | 0% | $275 |
Medium |
| Flouride - Topical Varnish Application | $43 | 0% | $43 |
Medium |
| Fluoride - Topical Application | $45 | 0% | $45 |
Medium |
| Maintenance Therapy - Periodontal | $158 | 0% | $158 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $289 | 0% | $289 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $93 | 0% | $93 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | 0% | $61 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $189 | 0% | $189 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
Medium |
| X-Ray - Complete Intraoral Series | $210 | 0% | $210 |
Medium |
| X-Ray - Four Images, Bitewings | $75 | 0% | $75 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | 0% | $36 |
Medium |
| X-Ray - Two Images, Bitewings | $53 | 0% | $53 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $135 | 0% | $135 |
Medium |
