| Dental Cleaning - Adult | $130 | 0% | $130 | 
Medium |
| Dental Cleaning - Child | $99 | 0% | $99 |
Medium |
| Dental Exam - Comprehensive | $110 | 0% | $110 |
Medium |
| Dental Exam - Periodic, Established Patient | $62 | 0% | $62 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $211 | 0% | $211 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $286 | 0% | $286 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $172 | 0% | $172 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $211 | 0% | $211 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $363 | 0% | $363 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $201 | 0% | $201 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $286 | 0% | $286 |
Medium |
| Flouride - Topical Varnish Application | $76 | 0% | $76 |
Medium |
| Fluoride - Topical Application | $46 | 0% | $46 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $408 | 0% | $408 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $108 | 0% | $108 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | 0% | $38 |
Medium |
| X-Ray - Complete Intraoral Series | $160 | 0% | $160 |
Medium |
| X-Ray - Four Images, Bitewings | $86 | 0% | $86 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
Medium |
| X-Ray - Two Images, Bitewings | $109 | 0% | $109 |
Medium |
