| Dental Cleaning - Adult | $129 | 0% | $129 | 
Medium |
| Dental Cleaning - Child | $118 | 0% | $118 |
Medium |
| Dental Exam - Comprehensive | $109 | 0% | $109 |
Medium |
| Dental Exam - Periodic, Established Patient | $68 | 0% | $68 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $252 | 0% | $252 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $290 | 0% | $290 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $322 | 0% | $322 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $208 | 0% | $208 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $252 | 0% | $252 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $395 | 0% | $395 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $287 | 0% | $287 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $322 | 0% | $322 |
Medium |
| Flouride - Topical Varnish Application | $45 | 0% | $45 |
Medium |
| Maintenance Therapy - Periodontal | $172 | 0% | $172 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $352 | 0% | $352 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | 0% | $95 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $67 | 0% | $67 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $40 | 0% | $40 |
Medium |
| X-Ray - Complete Intraoral Series | $186 | 0% | $186 |
Medium |
| X-Ray - Four Images, Bitewings | $89 | 0% | $89 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $45 | 0% | $45 |
Medium |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $153 | 0% | $153 |
Medium |
