| Dental Cleaning - Adult | $121 | 0% | $121 | 
Medium |
| Dental Cleaning - Child | $126 | 0% | $126 |
Medium |
| Dental Exam - Comprehensive | $95 | 0% | $95 |
Medium |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | 0% | $189 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $383 | 0% | $383 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $189 | 0% | $189 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | 0% | $189 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $284 | 0% | $284 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $242 | 0% | $242 |
Medium |
| Flouride - Topical Varnish Application | $63 | 0% | $63 |
Medium |
| Maintenance Therapy - Periodontal | $184 | 0% | $184 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $326 | 0% | $326 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $110 | 0% | $110 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $84 | 0% | $84 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $189 | 0% | $189 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
Medium |
| X-Ray - Complete Intraoral Series | $320 | 0% | $320 |
Medium |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
Medium |
| X-Ray - Two Images, Bitewings | $68 | 0% | $68 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $160 | 0% | $160 |
Medium |
