| Dental Cleaning - Adult | $126 | 0% | $126 | 
Medium |
| Dental Cleaning - Child | $77 | 0% | $77 |
Medium |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $289 | 0% | $289 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $239 | 0% | $239 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | 0% | $184 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $305 | 0% | $305 |
Medium |
| Fluoride - Topical Application | $47 | 0% | $47 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $273 | 0% | $273 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | 0% | $95 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $180 | 0% | $180 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $50 | 0% | $50 |
Medium |
| X-Ray - Complete Intraoral Series | $197 | 0% | $197 |
Medium |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
Medium |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $142 | 0% | $142 |
Medium |
