| Dental Cleaning - Adult | $214 | 0% | $214 | 
Medium |
| Dental Cleaning - Child | $168 | 0% | $168 |
Medium |
| Dental Exam - Comprehensive | $197 | 0% | $197 |
Medium |
| Dental Exam - Periodic, Established Patient | $111 | 0% | $111 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $250 | 0% | $250 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $344 | 0% | $344 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $192 | 0% | $192 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $213 | 0% | $213 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $344 | 0% | $344 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $234 | 0% | $234 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $267 | 0% | $267 |
Medium |
| Flouride - Topical Varnish Application | $46 | 0% | $46 |
Medium |
| Maintenance Therapy - Periodontal | $300 | 0% | $300 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $294 | 0% | $294 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | 0% | $88 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $206 | 0% | $206 |
Medium |
| X-Ray - Complete Intraoral Series | $298 | 0% | $298 |
Medium |
| X-Ray - Four Images, Bitewings | $147 | 0% | $147 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
Medium |
| X-Ray - Two Images, Bitewings | $105 | 0% | $105 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $134 | 0% | $134 |
Medium |
