| Dental Cleaning - Adult | $131 | 0% | $131 | 
Medium |
| Dental Cleaning - Child | $101 | 0% | $101 |
Medium |
| Dental Exam - Comprehensive | $118 | 0% | $118 |
Medium |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $223 | 0% | $223 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $305 | 0% | $305 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $194 | 0% | $194 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $223 | 0% | $223 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $372 | 0% | $372 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $239 | 0% | $239 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $305 | 0% | $305 |
Medium |
| Flouride - Topical Varnish Application | $53 | 0% | $53 |
Medium |
| Maintenance Therapy - Periodontal | $179 | 0% | $179 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $341 | 0% | $341 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | 0% | $105 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $70 | 0% | $70 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $236 | 0% | $236 |
Medium |
| X-Ray - Four Images, Bitewings | $83 | 0% | $83 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $47 | 0% | $47 |
Medium |
| X-Ray - Two Images, Bitewings | $58 | 0% | $58 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $172 | 0% | $172 |
Medium |
