| Dental Cleaning - Adult | $105 | 0% | $105 | 
Medium |
| Dental Cleaning - Child | $85 | 0% | $85 |
Medium |
| Dental Exam - Comprehensive | $121 | 0% | $121 |
Medium |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $205 | 0% | $205 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $352 | 0% | $352 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $273 | 0% | $273 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $191 | 0% | $191 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $205 | 0% | $205 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $352 | 0% | $352 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $231 | 0% | $231 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $273 | 0% | $273 |
Medium |
| Flouride - Topical Varnish Application | $43 | 0% | $43 |
Medium |
| Fluoride - Topical Application | $43 | 0% | $43 |
Medium |
| Maintenance Therapy - Periodontal | $158 | 0% | $158 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $310 | 0% | $310 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | 0% | $88 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $420 | 0% | $420 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
Medium |
| X-Ray - Complete Intraoral Series | $147 | 0% | $147 |
Medium |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
Medium |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
Medium |
