| Dental Cleaning - Adult | $111 | 0% | $111 | 
Medium |
| Dental Cleaning - Child | $84 | 0% | $84 |
Medium |
| Dental Exam - Comprehensive | $92 | 0% | $92 |
Medium |
| Dental Exam - Periodic, Established Patient | $50 | 0% | $50 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $186 | 0% | $186 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $314 | 0% | $314 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $188 | 0% | $188 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $185 | 0% | $185 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $338 | 0% | $338 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $460 | 0% | $460 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $272 | 0% | $272 |
Medium |
| Flouride - Topical Varnish Application | $49 | 0% | $49 |
Medium |
| Fluoride - Topical Application | $44 | 0% | $44 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $246 | 0% | $246 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $208 | 0% | $208 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
Medium |
| X-Ray - Complete Intraoral Series | $192 | 0% | $192 |
Medium |
| X-Ray - Four Images, Bitewings | $76 | 0% | $76 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
Medium |
| X-Ray - Two Images, Bitewings | $51 | 0% | $51 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $131 | 0% | $131 |
Medium |
