| Dental Cleaning - Adult | $90 | 0% | $90 | 
Medium |
| Dental Cleaning - Child | $85 | 0% | $85 |
Medium |
| Dental Exam - Comprehensive | $84 | 0% | $84 |
Medium |
| Dental Exam - Periodic, Established Patient | $42 | 0% | $42 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $155 | 0% | $155 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $246 | 0% | $246 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $197 | 0% | $197 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $128 | 0% | $128 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $155 | 0% | $155 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $246 | 0% | $246 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $226 | 0% | $226 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $197 | 0% | $197 |
Medium |
| Flouride - Topical Varnish Application | $41 | 0% | $41 |
Medium |
| Fluoride - Topical Application | $34 | 0% | $34 |
Medium |
| Maintenance Therapy - Periodontal | $151 | 0% | $151 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $276 | 0% | $276 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $76 | 0% | $76 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $200 | 0% | $200 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
Medium |
| X-Ray - Complete Intraoral Series | $132 | 0% | $132 |
Medium |
| X-Ray - Four Images, Bitewings | $59 | 0% | $59 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $28 | 0% | $28 |
Medium |
| X-Ray - Two Images, Bitewings | $46 | 0% | $46 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $118 | 0% | $118 |
Medium |
