| Dental Cleaning - Adult | $109 | 0% | $109 | 
Medium |
| Dental Cleaning - Child | $92 | 0% | $92 |
Medium |
| Dental Exam - Comprehensive | $95 | 0% | $95 |
Medium |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $273 | 0% | $273 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $394 | 0% | $394 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $334 | 0% | $334 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $181 | 0% | $181 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $273 | 0% | $273 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $383 | 0% | $383 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $342 | 0% | $342 |
Medium |
| Fluoride - Topical Application | $48 | 0% | $48 |
Medium |
| Maintenance Therapy - Periodontal | $176 | 0% | $176 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $296 | 0% | $296 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $91 | 0% | $91 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $226 | 0% | $226 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | 0% | $30 |
Medium |
| X-Ray - Complete Intraoral Series | $147 | 0% | $147 |
Medium |
| X-Ray - Four Images, Bitewings | $76 | 0% | $76 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | 0% | $36 |
Medium |
| X-Ray - Two Images, Bitewings | $59 | 0% | $59 |
Medium |
