| Dental Cleaning - Adult | $114 | 0% | $114 | 
Medium |
| Dental Cleaning - Child | $98 | 0% | $98 |
Medium |
| Dental Exam - Comprehensive | $127 | 0% | $127 |
Medium |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $393 | 0% | $393 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $275 | 0% | $275 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | 0% | $184 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $196 | 0% | $196 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $358 | 0% | $358 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $228 | 0% | $228 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $275 | 0% | $275 |
Medium |
| Flouride - Topical Varnish Application | $43 | 0% | $43 |
Medium |
| Fluoride - Topical Application | $46 | 0% | $46 |
Medium |
| Maintenance Therapy - Periodontal | $163 | 0% | $163 |
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 | $142 | 0% | $142 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | 0% | $61 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $264 | 0% | $264 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | 0% | $30 |
Medium |
| X-Ray - Complete Intraoral Series | $210 | 0% | $210 |
Medium |
| X-Ray - Four Images, Bitewings | $77 | 0% | $77 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $55 | 0% | $55 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $140 | 0% | $140 |
Medium |
