| Dental Cleaning - Adult | $126 | 0% | $126 | 
Medium |
| Dental Cleaning - Child | $97 | 0% | $97 |
Medium |
| Dental Exam - Comprehensive | $189 | 0% | $189 |
Medium |
| Dental Exam - Periodic, Established Patient | $72 | 0% | $72 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $219 | 0% | $219 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $364 | 0% | $364 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $249 | 0% | $249 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $251 | 0% | $251 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $251 | 0% | $251 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $427 | 0% | $427 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $323 | 0% | $323 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $323 | 0% | $323 |
Medium |
| Fluoride - Topical Application | $61 | 0% | $61 |
Medium |
| Maintenance Therapy - Periodontal | $328 | 0% | $328 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $263 | 0% | $263 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $143 | 0% | $143 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $78 | 0% | $78 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $273 | 0% | $273 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
Medium |
| X-Ray - Complete Intraoral Series | $198 | 0% | $198 |
Medium |
| X-Ray - Four Images, Bitewings | $133 | 0% | $133 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | 0% | $46 |
Medium |
| X-Ray - Two Images, Bitewings | $91 | 0% | $91 |
Medium |
