| Dental Cleaning - Adult | $116 | 0% | $116 | 
Medium |
| Dental Cleaning - Child | $91 | 0% | $91 |
Medium |
| Dental Exam - Comprehensive | $98 | 0% | $98 |
Medium |
| Dental Exam - Periodic, Established Patient | $59 | 0% | $59 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $184 | 0% | $184 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $296 | 0% | $296 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $228 | 0% | $228 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | 0% | $184 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $184 | 0% | $184 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $592 | 0% | $592 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $445 | 0% | $445 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $228 | 0% | $228 |
Medium |
| Flouride - Topical Varnish Application | $49 | 0% | $49 |
Medium |
| Fluoride - Topical Application | $42 | 0% | $42 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $96 | 0% | $96 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $62 | 0% | $62 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $205 | 0% | $205 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | 0% | $33 |
Medium |
| X-Ray - Complete Intraoral Series | $198 | 0% | $198 |
Medium |
| X-Ray - Four Images, Bitewings | $77 | 0% | $77 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
Medium |
| X-Ray - Two Images, Bitewings | $55 | 0% | $55 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $144 | 0% | $144 |
Medium |
