| Dental Cleaning - Adult | $124 | 0% | $124 | 
Medium |
| Dental Cleaning - Child | $92 | 0% | $92 |
Medium |
| Dental Exam - Comprehensive | $113 | 0% | $113 |
Medium |
| Dental Exam - Periodic, Established Patient | $70 | 0% | $70 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $229 | 0% | $229 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $365 | 0% | $365 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $296 | 0% | $296 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $212 | 0% | $212 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $229 | 0% | $229 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $365 | 0% | $365 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $260 | 0% | $260 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $296 | 0% | $296 |
Medium |
| Flouride - Topical Varnish Application | $59 | 0% | $59 |
Medium |
| Maintenance Therapy - Periodontal | $190 | 0% | $190 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $344 | 0% | $344 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | 0% | $103 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $70 | 0% | $70 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $238 | 0% | $238 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
Medium |
| X-Ray - Complete Intraoral Series | $176 | 0% | $176 |
Medium |
| X-Ray - Four Images, Bitewings | $88 | 0% | $88 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
Medium |
| X-Ray - Two Images, Bitewings | $57 | 0% | $57 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $141 | 0% | $141 |
Medium |
