| Dental Cleaning - Adult | $109 | 0% | $109 | 
Medium |
| Dental Cleaning - Child | $113 | 0% | $113 |
Medium |
| Dental Exam - Comprehensive | $99 | 0% | $99 |
Medium |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $218 | 0% | $218 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $247 | 0% | $247 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $207 | 0% | $207 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $326 | 0% | $326 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $326 | 0% | $326 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $468 | 0% | $468 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $189 | 0% | $189 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $415 | 0% | $415 |
Medium |
| Flouride - Topical Varnish Application | $53 | 0% | $53 |
Medium |
| Maintenance Therapy - Periodontal | $294 | 0% | $294 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $85 | 0% | $85 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $191 | 0% | $191 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
Medium |
| X-Ray - Complete Intraoral Series | $185 | 0% | $185 |
Medium |
| X-Ray - Four Images, Bitewings | $82 | 0% | $82 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
Medium |
| X-Ray - Two Images, Bitewings | $60 | 0% | $60 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $170 | 0% | $170 |
Medium |
