| Dental Cleaning - Adult | $123 | 0% | $123 | 
Medium |
| Dental Cleaning - Child | $91 | 0% | $91 |
Medium |
| Dental Exam - Comprehensive | $107 | 0% | $107 |
Medium |
| Dental Exam - Periodic, Established Patient | $59 | 0% | $59 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $228 | 0% | $228 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $370 | 0% | $370 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $291 | 0% | $291 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $225 | 0% | $225 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $228 | 0% | $228 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $362 | 0% | $362 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $274 | 0% | $274 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $286 | 0% | $286 |
Medium |
| Flouride - Topical Varnish Application | $56 | 0% | $56 |
Medium |
| Fluoride - Topical Application | $49 | 0% | $49 |
Medium |
| Maintenance Therapy - Periodontal | $176 | 0% | $176 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $326 | 0% | $326 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $98 | 0% | $98 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $70 | 0% | $70 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $228 | 0% | $228 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
Medium |
| X-Ray - Complete Intraoral Series | $176 | 0% | $176 |
Medium |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
Medium |
| X-Ray - Two Images, Bitewings | $58 | 0% | $58 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $147 | 0% | $147 |
Medium |
