| Dental Cleaning - Adult | $120 | 0% | $120 | 
Medium |
| Dental Cleaning - Child | $128 | 0% | $128 |
Medium |
| Dental Exam - Comprehensive | $112 | 0% | $112 |
Medium |
| Dental Exam - Periodic, Established Patient | $61 | 0% | $61 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $221 | 0% | $221 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $315 | 0% | $315 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $268 | 0% | $268 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $187 | 0% | $187 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | 0% | $221 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | 0% | $342 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $239 | 0% | $239 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $255 | 0% | $255 |
Medium |
| Fluoride - Topical Application | $49 | 0% | $49 |
Medium |
| Maintenance Therapy - Periodontal | $179 | 0% | $179 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $298 | 0% | $298 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $142 | 0% | $142 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | 0% | $74 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
Medium |
| X-Ray - Complete Intraoral Series | $179 | 0% | $179 |
Medium |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
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 | $168 | 0% | $168 |
Medium |
