| Dental Cleaning - Adult | $109 | 0% | $109 | 
Medium |
| Dental Cleaning - Child | $77 | 0% | $77 |
Medium |
| Dental Exam - Comprehensive | $92 | 0% | $92 |
Medium |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $195 | 0% | $195 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $309 | 0% | $309 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $249 | 0% | $249 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $169 | 0% | $169 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $207 | 0% | $207 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $232 | 0% | $232 |
Medium |
| Flouride - Topical Varnish Application | $47 | 0% | $47 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $79 | 0% | $79 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $192 | 0% | $192 |
Medium |
| X-Ray - Complete Intraoral Series | $213 | 0% | $213 |
Medium |
| X-Ray - Four Images, Bitewings | $70 | 0% | $70 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
Medium |
| X-Ray - Two Images, Bitewings | $49 | 0% | $49 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $143 | 0% | $143 |
Medium |
