| Dental Cleaning - Adult | $99 | 0% | $99 | 
Medium |
| Dental Cleaning - Child | $75 | 0% | $75 |
Medium |
| Dental Exam - Comprehensive | $77 | 0% | $77 |
Medium |
| Dental Exam - Periodic, Established Patient | $46 | 0% | $46 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $156 | 0% | $156 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $272 | 0% | $272 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $205 | 0% | $205 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $143 | 0% | $143 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $158 | 0% | $158 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $272 | 0% | $272 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $177 | 0% | $177 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $207 | 0% | $207 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $70 | 0% | $70 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $111 | 0% | $111 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $161 | 0% | $161 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $23 | 0% | $23 |
Medium |
| X-Ray - Complete Intraoral Series | $139 | 0% | $139 |
Medium |
| X-Ray - Four Images, Bitewings | $64 | 0% | $64 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $28 | 0% | $28 |
Medium |
| X-Ray - Two Images, Bitewings | $43 | 0% | $43 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $112 | 0% | $112 |
Medium |
