| Dental Cleaning - Adult | $130 | 0% | $130 | 
Medium |
| Dental Cleaning - Child | $101 | 0% | $101 |
Medium |
| Dental Exam - Comprehensive | $137 | 0% | $137 |
Medium |
| Dental Exam - Periodic, Established Patient | $76 | 0% | $76 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $267 | 0% | $267 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $404 | 0% | $404 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $331 | 0% | $331 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $237 | 0% | $237 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $267 | 0% | $267 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $404 | 0% | $404 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $287 | 0% | $287 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $331 | 0% | $331 |
Medium |
| Flouride - Topical Varnish Application | $64 | 0% | $64 |
Medium |
| Maintenance Therapy - Periodontal | $210 | 0% | $210 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $365 | 0% | $365 |
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 | $81 | 0% | $81 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $275 | 0% | $275 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | 0% | $38 |
Medium |
| X-Ray - Complete Intraoral Series | $189 | 0% | $189 |
Medium |
| X-Ray - Four Images, Bitewings | $93 | 0% | $93 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $45 | 0% | $45 |
Medium |
| X-Ray - Two Images, Bitewings | $65 | 0% | $65 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $162 | 0% | $162 |
Medium |
