| Dental Cleaning - Adult | $128 | 0% | $128 | 
Medium |
| Dental Cleaning - Child | $102 | 0% | $102 |
Medium |
| Dental Exam - Comprehensive | $165 | 0% | $165 |
Medium |
| Dental Exam - Periodic, Established Patient | $57 | 0% | $57 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $224 | 0% | $224 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $377 | 0% | $377 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $276 | 0% | $276 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $214 | 0% | $214 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $224 | 0% | $224 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $377 | 0% | $377 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $229 | 0% | $229 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $276 | 0% | $276 |
Medium |
| Flouride - Topical Varnish Application | $49 | 0% | $49 |
Medium |
| Fluoride - Topical Application | $47 | 0% | $47 |
Medium |
| Maintenance Therapy - Periodontal | $173 | 0% | $173 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $297 | 0% | $297 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $83 | 0% | $83 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $64 | 0% | $64 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $215 | 0% | $215 |
Medium |
| X-Ray - Complete Intraoral Series | $189 | 0% | $189 |
Medium |
| X-Ray - Four Images, Bitewings | $87 | 0% | $87 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $49 | 0% | $49 |
Medium |
| X-Ray - Two Images, Bitewings | $59 | 0% | $59 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $181 | 0% | $181 |
Medium |
