| Dental Cleaning - Adult | $108 | 0% | $108 | 
Medium |
| Dental Cleaning - Child | $95 | 0% | $95 |
Medium |
| Dental Exam - Comprehensive | $90 | 0% | $90 |
Medium |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
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 | $265 | 0% | $265 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $193 | 0% | $193 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $348 | 0% | $348 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $202 | 0% | $202 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $270 | 0% | $270 |
Medium |
| Flouride - Topical Varnish Application | $42 | 0% | $42 |
Medium |
| Maintenance Therapy - Periodontal | $151 | 0% | $151 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $275 | 0% | $275 |
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 | $59 | 0% | $59 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $182 | 0% | $182 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
Medium |
| X-Ray - Complete Intraoral Series | $149 | 0% | $149 |
Medium |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
Medium |
| X-Ray - Two Images, Bitewings | $55 | 0% | $55 |
Medium |
