| Dental Cleaning - Adult | $97 | 0% | $97 | 
Medium |
| Dental Cleaning - Child | $78 | 0% | $78 |
Medium |
| Dental Exam - Comprehensive | $83 | 0% | $83 |
Medium |
| Dental Exam - Periodic, Established Patient | $46 | 0% | $46 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $200 | 0% | $200 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $280 | 0% | $280 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $294 | 0% | $294 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $344 | 0% | $344 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $334 | 0% | $334 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $261 | 0% | $261 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $447 | 0% | $447 |
Medium |
| Flouride - Topical Varnish Application | $45 | 0% | $45 |
Medium |
| Fluoride - Topical Application | $42 | 0% | $42 |
Medium |
| Maintenance Therapy - Periodontal | $143 | 0% | $143 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $229 | 0% | $229 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $80 | 0% | $80 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $151 | 0% | $151 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $24 | 0% | $24 |
Medium |
| X-Ray - Complete Intraoral Series | $143 | 0% | $143 |
Medium |
| X-Ray - Four Images, Bitewings | $65 | 0% | $65 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $30 | 0% | $30 |
Medium |
| X-Ray - Two Images, Bitewings | $47 | 0% | $47 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $126 | 0% | $126 |
Medium |
