| Dental Cleaning - Adult | $118 | 0% | $118 | 
Medium |
| Dental Cleaning - Child | $99 | 0% | $99 |
Medium |
| Dental Exam - Comprehensive | $135 | 0% | $135 |
Medium |
| Dental Exam - Periodic, Established Patient | $65 | 0% | $65 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $233 | 0% | $233 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $394 | 0% | $394 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $314 | 0% | $314 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $230 | 0% | $230 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $233 | 0% | $233 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $394 | 0% | $394 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $270 | 0% | $270 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $314 | 0% | $314 |
Medium |
| Flouride - Topical Varnish Application | $61 | 0% | $61 |
Medium |
| Fluoride - Topical Application | $55 | 0% | $55 |
Medium |
| Maintenance Therapy - Periodontal | $170 | 0% | $170 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $336 | 0% | $336 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $104 | 0% | $104 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $80 | 0% | $80 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $247 | 0% | $247 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | 0% | $36 |
Medium |
| X-Ray - Complete Intraoral Series | $184 | 0% | $184 |
Medium |
| X-Ray - Four Images, Bitewings | $92 | 0% | $92 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | 0% | $46 |
Medium |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $176 | 0% | $176 |
Medium |
