| Dental Cleaning - Adult | $113 | 0% | $113 | 
Medium |
| Dental Cleaning - Child | $91 | 0% | $91 |
Medium |
| Dental Exam - Comprehensive | $104 | 0% | $104 |
Medium |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $188 | 0% | $188 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $255 | 0% | $255 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $227 | 0% | $227 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $208 | 0% | $208 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $235 | 0% | $235 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $365 | 0% | $365 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $238 | 0% | $238 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $281 | 0% | $281 |
Medium |
| Fluoride - Topical Application | $46 | 0% | $46 |
Medium |
| Maintenance Therapy - Periodontal | $167 | 0% | $167 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $327 | 0% | $327 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $142 | 0% | $142 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $64 | 0% | $64 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $202 | 0% | $202 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
Medium |
| X-Ray - Complete Intraoral Series | $179 | 0% | $179 |
Medium |
| X-Ray - Four Images, Bitewings | $81 | 0% | $81 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $171 | 0% | $171 |
Medium |
