| Dental Cleaning - Adult | $116 | 0% | $116 | 
Medium |
| Dental Cleaning - Child | $86 | 0% | $86 |
Medium |
| Dental Exam - Comprehensive | $100 | 0% | $100 |
Medium |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $221 | 0% | $221 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $373 | 0% | $373 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $273 | 0% | $273 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $179 | 0% | $179 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | 0% | $221 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $373 | 0% | $373 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $202 | 0% | $202 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $294 | 0% | $294 |
Medium |
| Maintenance Therapy - Periodontal | $152 | 0% | $152 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $278 | 0% | $278 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $87 | 0% | $87 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $57 | 0% | $57 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $268 | 0% | $268 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
Medium |
| X-Ray - Complete Intraoral Series | $223 | 0% | $223 |
Medium |
| X-Ray - Four Images, Bitewings | $76 | 0% | $76 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
Medium |
| X-Ray - Two Images, Bitewings | $55 | 0% | $55 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $147 | 0% | $147 |
Medium |
