| Dental Cleaning - Adult | $126 | 0% | $126 | 
Medium |
| Dental Cleaning - Child | $87 | 0% | $87 |
Medium |
| Dental Exam - Comprehensive | $116 | 0% | $116 |
Medium |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $357 | 0% | $357 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $289 | 0% | $289 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $242 | 0% | $242 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $357 | 0% | $357 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $289 | 0% | $289 |
Medium |
| Flouride - Topical Varnish Application | $58 | 0% | $58 |
Medium |
| Fluoride - Topical Application | $50 | 0% | $50 |
Medium |
| Maintenance Therapy - Periodontal | $191 | 0% | $191 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $326 | 0% | $326 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $159 | 0% | $159 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
Medium |
| X-Ray - Complete Intraoral Series | $210 | 0% | $210 |
Medium |
| X-Ray - Four Images, Bitewings | $100 | 0% | $100 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $75 | 0% | $75 |
Medium |
