| Dental Cleaning - Adult | $128 | 0% | $128 | 
Medium |
| Dental Cleaning - Child | $92 | 0% | $92 |
Medium |
| Dental Exam - Periodic, Established Patient | $59 | 0% | $59 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $326 | 0% | $326 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $405 | 0% | $405 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $378 | 0% | $378 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $326 | 0% | $326 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $405 | 0% | $405 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $378 | 0% | $378 |
Medium |
| Flouride - Topical Varnish Application | $42 | 0% | $42 |
Medium |
| Fluoride - Topical Application | $43 | 0% | $43 |
Medium |
| Maintenance Therapy - Periodontal | $271 | 0% | $271 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $389 | 0% | $389 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $130 | 0% | $130 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $374 | 0% | $374 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $23 | 0% | $23 |
Medium |
| X-Ray - Complete Intraoral Series | $158 | 0% | $158 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $33 | 0% | $33 |
Medium |
| X-Ray - Two Images, Bitewings | $43 | 0% | $43 |
Medium |
