| Dental Cleaning - Adult | $116 | 0% | $116 | 
Medium |
| Dental Cleaning - Child | $89 | 0% | $89 |
Medium |
| Dental Exam - Comprehensive | $100 | 0% | $100 |
Medium |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | 0% | $189 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $294 | 0% | $294 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | 0% | $263 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $192 | 0% | $192 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $208 | 0% | $208 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $320 | 0% | $320 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $231 | 0% | $231 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
Medium |
| Flouride - Topical Varnish Application | $51 | 0% | $51 |
Medium |
| Fluoride - Topical Application | $46 | 0% | $46 |
Medium |
| Maintenance Therapy - Periodontal | $166 | 0% | $166 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $284 | 0% | $284 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | 0% | $95 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | 0% | $69 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $221 | 0% | $221 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $17 | 0% | $17 |
Medium |
| X-Ray - Complete Intraoral Series | $168 | 0% | $168 |
Medium |
| X-Ray - Four Images, Bitewings | $92 | 0% | $92 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
Medium |
| X-Ray - Two Images, Bitewings | $70 | 0% | $70 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $141 | 0% | $141 |
Medium |
