| Dental Cleaning - Adult | $113 | 0% | $113 | 
Medium |
| Dental Cleaning - Child | $95 | 0% | $95 |
Medium |
| Dental Exam - Comprehensive | $95 | 0% | $95 |
Medium |
| Dental Exam - Periodic, Established Patient | $51 | 0% | $51 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $193 | 0% | $193 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $348 | 0% | $348 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $270 | 0% | $270 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $165 | 0% | $165 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $198 | 0% | $198 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $365 | 0% | $365 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $212 | 0% | $212 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $284 | 0% | $284 |
Medium |
| Flouride - Topical Varnish Application | $44 | 0% | $44 |
Medium |
| Maintenance Therapy - Periodontal | $159 | 0% | $159 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $308 | 0% | $308 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | 0% | $92 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | 0% | $59 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $399 | 0% | $399 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
Medium |
| X-Ray - Complete Intraoral Series | $156 | 0% | $156 |
Medium |
| X-Ray - Four Images, Bitewings | $75 | 0% | $75 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
Medium |
| X-Ray - Two Images, Bitewings | $53 | 0% | $53 |
Medium |
