| Dental Cleaning - Adult | $155 | 0% | $155 | 
Medium |
| Dental Cleaning - Child | $120 | 0% | $120 |
Medium |
| Dental Exam - Comprehensive | $100 | 0% | $100 |
Medium |
| Dental Exam - Periodic, Established Patient | $74 | 0% | $74 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $194 | 0% | $194 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $300 | 0% | $300 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $194 | 0% | $194 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $177 | 0% | $177 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $194 | 0% | $194 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $300 | 0% | $300 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | 0% | $271 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $321 | 0% | $321 |
Medium |
| Fluoride - Topical Application | $69 | 0% | $69 |
Medium |
| Maintenance Therapy - Periodontal | $212 | 0% | $212 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $278 | 0% | $278 |
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 | $80 | 0% | $80 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $194 | 0% | $194 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $25 | 0% | $25 |
Medium |
| X-Ray - Complete Intraoral Series | $197 | 0% | $197 |
Medium |
| X-Ray - Four Images, Bitewings | $95 | 0% | $95 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
Medium |
| X-Ray - Two Images, Bitewings | $76 | 0% | $76 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $185 | 0% | $185 |
Medium |
