| Dental Cleaning - Adult | $126 | 0% | $126 | 
Medium |
| Dental Cleaning - Child | $92 | 0% | $92 |
Medium |
| Dental Exam - Comprehensive | $102 | 0% | $102 |
Medium |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $173 | 0% | $173 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $347 | 0% | $347 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $336 | 0% | $336 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $173 | 0% | $173 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $200 | 0% | $200 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $349 | 0% | $349 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $210 | 0% | $210 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $273 | 0% | $273 |
Medium |
| Flouride - Topical Varnish Application | $47 | 0% | $47 |
Medium |
| Fluoride - Topical Application | $47 | 0% | $47 |
Medium |
| Maintenance Therapy - Periodontal | $158 | 0% | $158 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | 0% | $100 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $368 | 0% | $368 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | 0% | $38 |
Medium |
| X-Ray - Complete Intraoral Series | $158 | 0% | $158 |
Medium |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
Medium |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
Medium |
