| Dental Cleaning - Adult | $160 | 0% | $160 | 
Medium |
| Dental Cleaning - Child | $117 | 0% | $117 |
Medium |
| Dental Exam - Comprehensive | $86 | 0% | $86 |
Medium |
| Dental Exam - Periodic, Established Patient | $66 | 0% | $66 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $282 | 0% | $282 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $421 | 0% | $421 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $355 | 0% | $355 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $250 | 0% | $250 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $282 | 0% | $282 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $408 | 0% | $408 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $277 | 0% | $277 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $355 | 0% | $355 |
Medium |
| Maintenance Therapy - Periodontal | $176 | 0% | $176 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $321 | 0% | $321 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $114 | 0% | $114 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $91 | 0% | $91 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $367 | 0% | $367 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $39 | 0% | $39 |
Medium |
| X-Ray - Complete Intraoral Series | $315 | 0% | $315 |
Medium |
| X-Ray - Four Images, Bitewings | $99 | 0% | $99 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $49 | 0% | $49 |
Medium |
| X-Ray - Two Images, Bitewings | $83 | 0% | $83 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $207 | 0% | $207 |
Medium |
