| Dental Cleaning - Adult | $116 | 0% | $116 | 
Medium |
| Dental Cleaning - Child | $105 | 0% | $105 |
Medium |
| Dental Exam - Comprehensive | $107 | 0% | $107 |
Medium |
| Dental Exam - Periodic, Established Patient | $79 | 0% | $79 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $181 | 0% | $181 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $289 | 0% | $289 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $231 | 0% | $231 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $165 | 0% | $165 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $181 | 0% | $181 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $378 | 0% | $378 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $238 | 0% | $238 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $243 | 0% | $243 |
Medium |
| Fluoride - Topical Application | $75 | 0% | $75 |
Medium |
| Maintenance Therapy - Periodontal | $183 | 0% | $183 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $310 | 0% | $310 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | 0% | $100 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $79 | 0% | $79 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $53 | 0% | $53 |
Medium |
| X-Ray - Complete Intraoral Series | $149 | 0% | $149 |
Medium |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $53 | 0% | $53 |
Medium |
| X-Ray - Two Images, Bitewings | $70 | 0% | $70 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $144 | 0% | $144 |
Medium |
