| Dental Cleaning - Adult | $97 | 0% | $97 | 
Medium |
| Dental Cleaning - Child | $78 | 0% | $78 |
Medium |
| Dental Exam - Comprehensive | $109 | 0% | $109 |
Medium |
| Dental Exam - Periodic, Established Patient | $46 | 0% | $46 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $156 | 0% | $156 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $236 | 0% | $236 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $201 | 0% | $201 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $160 | 0% | $160 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $173 | 0% | $173 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $272 | 0% | $272 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $226 | 0% | $226 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $223 | 0% | $223 |
Medium |
| Flouride - Topical Varnish Application | $46 | 0% | $46 |
Medium |
| Fluoride - Topical Application | $39 | 0% | $39 |
Medium |
| Maintenance Therapy - Periodontal | $140 | 0% | $140 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $207 | 0% | $207 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $80 | 0% | $80 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | 0% | $61 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $205 | 0% | $205 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $24 | 0% | $24 |
Medium |
| X-Ray - Complete Intraoral Series | $144 | 0% | $144 |
Medium |
| X-Ray - Four Images, Bitewings | $88 | 0% | $88 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $30 | 0% | $30 |
Medium |
| X-Ray - Two Images, Bitewings | $57 | 0% | $57 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $119 | 0% | $119 |
Medium |
