| Dental Cleaning - Adult | $105 | 0% | $105 | 
Medium |
| Dental Cleaning - Child | $85 | 0% | $85 |
Medium |
| Dental Exam - Comprehensive | $91 | 0% | $91 |
Medium |
| Dental Exam - Periodic, Established Patient | $50 | 0% | $50 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $145 | 0% | $145 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $222 | 0% | $222 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $182 | 0% | $182 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $165 | 0% | $165 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | 0% | $189 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | 0% | $342 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $205 | 0% | $205 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
Medium |
| Fluoride - Topical Application | $43 | 0% | $43 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $278 | 0% | $278 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $183 | 0% | $183 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
Medium |
| X-Ray - Complete Intraoral Series | $148 | 0% | $148 |
Medium |
| X-Ray - Four Images, Bitewings | $72 | 0% | $72 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
Medium |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $131 | 0% | $131 |
Medium |
