| Dental Cleaning - Adult | $120 | 0% | $120 | 
Medium |
| Dental Cleaning - Child | $87 | 0% | $87 |
Medium |
| Dental Exam - Comprehensive | $182 | 0% | $182 |
Medium |
| Dental Exam - Periodic, Established Patient | $55 | 0% | $55 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $211 | 0% | $211 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $228 | 0% | $228 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $211 | 0% | $211 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $201 | 0% | $201 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $211 | 0% | $211 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $338 | 0% | $338 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $237 | 0% | $237 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $273 | 0% | $273 |
Medium |
| Fluoride - Topical Application | $43 | 0% | $43 |
Medium |
| Maintenance Therapy - Periodontal | $200 | 0% | $200 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $426 | 0% | $426 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $121 | 0% | $121 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | 0% | $60 |
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 | $36 | 0% | $36 |
Medium |
| X-Ray - Complete Intraoral Series | $188 | 0% | $188 |
Medium |
| X-Ray - Four Images, Bitewings | $80 | 0% | $80 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $61 | 0% | $61 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $173 | 0% | $173 |
Medium |
