| Dental Cleaning - Adult | $140 | 0% | $140 | 
Medium |
| Dental Cleaning - Child | $112 | 0% | $112 |
Medium |
| Dental Exam - Comprehensive | $98 | 0% | $98 |
Medium |
| Dental Exam - Periodic, Established Patient | $74 | 0% | $74 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $226 | 0% | $226 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $287 | 0% | $287 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $289 | 0% | $289 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $212 | 0% | $212 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $319 | 0% | $319 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $406 | 0% | $406 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $207 | 0% | $207 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $360 | 0% | $360 |
Medium |
| Flouride - Topical Varnish Application | $58 | 0% | $58 |
Medium |
| Fluoride - Topical Application | $49 | 0% | $49 |
Medium |
| Maintenance Therapy - Periodontal | $173 | 0% | $173 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $300 | 0% | $300 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $86 | 0% | $86 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $76 | 0% | $76 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $236 | 0% | $236 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
Medium |
| X-Ray - Complete Intraoral Series | $201 | 0% | $201 |
Medium |
| X-Ray - Four Images, Bitewings | $92 | 0% | $92 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
Medium |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $158 | 0% | $158 |
Medium |
