| Dental Cleaning - Adult | $133 | 0% | $133 | 
Medium |
| Dental Cleaning - Child | $100 | 0% | $100 |
Medium |
| Dental Exam - Comprehensive | $121 | 0% | $121 |
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 | $312 | 0% | $312 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $289 | 0% | $289 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $239 | 0% | $239 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $212 | 0% | $212 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $347 | 0% | $347 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $207 | 0% | $207 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $337 | 0% | $337 |
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 | $151 | 0% | $151 |
Medium |
| X-Ray - Four Images, Bitewings | $91 | 0% | $91 |
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 |
