| Dental Cleaning - Adult | $106 | 0% | $106 | 
Medium |
| Dental Cleaning - Child | $85 | 0% | $85 |
Medium |
| Dental Exam - Comprehensive | $89 | 0% | $89 |
Medium |
| Dental Exam - Periodic, Established Patient | $51 | 0% | $51 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $171 | 0% | $171 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $251 | 0% | $251 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $202 | 0% | $202 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $204 | 0% | $204 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $209 | 0% | $209 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $362 | 0% | $362 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $228 | 0% | $228 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $286 | 0% | $286 |
Medium |
| Flouride - Topical Varnish Application | $51 | 0% | $51 |
Medium |
| Maintenance Therapy - Periodontal | $147 | 0% | $147 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $260 | 0% | $260 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $85 | 0% | $85 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | 0% | $61 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $194 | 0% | $194 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
Medium |
| X-Ray - Complete Intraoral Series | $147 | 0% | $147 |
Medium |
| X-Ray - Four Images, Bitewings | $74 | 0% | $74 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
Medium |
| X-Ray - Two Images, Bitewings | $49 | 0% | $49 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $124 | 0% | $124 |
Medium |
