| Dental Cleaning - Adult | $122 | 0% | $122 | 
Medium |
| Dental Cleaning - Child | $98 | 0% | $98 |
Medium |
| Dental Exam - Periodic, Established Patient | $62 | 0% | $62 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $222 | 0% | $222 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $257 | 0% | $257 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $211 | 0% | $211 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $222 | 0% | $222 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $364 | 0% | $364 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $251 | 0% | $251 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $293 | 0% | $293 |
Medium |
| Flouride - Topical Varnish Application | $48 | 0% | $48 |
Medium |
| Maintenance Therapy - Periodontal | $176 | 0% | $176 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $336 | 0% | $336 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $139 | 0% | $139 |
Medium |
| X-Ray - Complete Intraoral Series | $188 | 0% | $188 |
Medium |
| X-Ray - Four Images, Bitewings | $83 | 0% | $83 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $141 | 0% | $141 |
Medium |
