| Dental Cleaning - Adult | $114 | 0% | $114 | 
Medium |
| Dental Cleaning - Child | $97 | 0% | $97 |
Medium |
| Dental Exam - Comprehensive | $102 | 0% | $102 |
Medium |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $215 | 0% | $215 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | 0% | $326 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $267 | 0% | $267 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $254 | 0% | $254 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $226 | 0% | $226 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $460 | 0% | $460 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $299 | 0% | $299 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $321 | 0% | $321 |
Medium |
| Flouride - Topical Varnish Application | $77 | 0% | $77 |
Medium |
| Fluoride - Topical Application | $69 | 0% | $69 |
Medium |
| Maintenance Therapy - Periodontal | $172 | 0% | $172 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $316 | 0% | $316 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $108 | 0% | $108 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $89 | 0% | $89 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $273 | 0% | $273 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
Medium |
| X-Ray - Complete Intraoral Series | $170 | 0% | $170 |
Medium |
| X-Ray - Four Images, Bitewings | $120 | 0% | $120 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $53 | 0% | $53 |
Medium |
| X-Ray - Two Images, Bitewings | $76 | 0% | $76 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $164 | 0% | $164 |
Medium |
