| Dental Cleaning - Adult | $128 | 0% | $128 | 
Medium |
| Dental Cleaning - Child | $104 | 0% | $104 |
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 | $219 | 0% | $219 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $550 | 0% | $550 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $230 | 0% | $230 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $205 | 0% | $205 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $219 | 0% | $219 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $358 | 0% | $358 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $246 | 0% | $246 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $300 | 0% | $300 |
Medium |
| Flouride - Topical Varnish Application | $53 | 0% | $53 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $320 | 0% | $320 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $106 | 0% | $106 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $79 | 0% | $79 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $209 | 0% | $209 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $39 | 0% | $39 |
Medium |
| X-Ray - Complete Intraoral Series | $200 | 0% | $200 |
Medium |
| X-Ray - Four Images, Bitewings | $95 | 0% | $95 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
Medium |
| X-Ray - Two Images, Bitewings | $71 | 0% | $71 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $179 | 0% | $179 |
Medium |
