| Dental Cleaning - Adult | $106 | 0% | $106 | 
Medium |
| Dental Cleaning - Child | $84 | 0% | $84 |
Medium |
| Dental Exam - Comprehensive | $92 | 0% | $92 |
Medium |
| Dental Exam - Periodic, Established Patient | $50 | 0% | $50 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $183 | 0% | $183 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | 0% | $342 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $264 | 0% | $264 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $168 | 0% | $168 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $183 | 0% | $183 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $351 | 0% | $351 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $206 | 0% | $206 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $264 | 0% | $264 |
Medium |
| Maintenance Therapy - Periodontal | $145 | 0% | $145 |
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 | $88 | 0% | $88 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
Medium |
| X-Ray - Complete Intraoral Series | $200 | 0% | $200 |
Medium |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
Medium |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $130 | 0% | $130 |
Medium |
