| Dental Cleaning - Adult | $118 | 0% | $118 | 
Medium |
| Dental Cleaning - Child | $82 | 0% | $82 |
Medium |
| Dental Exam - Comprehensive | $173 | 0% | $173 |
Medium |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $242 | 0% | $242 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $374 | 0% | $374 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $297 | 0% | $297 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $207 | 0% | $207 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $242 | 0% | $242 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $383 | 0% | $383 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $252 | 0% | $252 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $297 | 0% | $297 |
Medium |
| Fluoride - Topical Application | $47 | 0% | $47 |
Medium |
| Maintenance Therapy - Periodontal | $195 | 0% | $195 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $297 | 0% | $297 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $110 | 0% | $110 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $82 | 0% | $82 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
Medium |
| X-Ray - Complete Intraoral Series | $182 | 0% | $182 |
Medium |
| X-Ray - Four Images, Bitewings | $93 | 0% | $93 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $47 | 0% | $47 |
Medium |
| X-Ray - Two Images, Bitewings | $74 | 0% | $74 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $171 | 0% | $171 |
Medium |
