| Dental Cleaning - Adult | $117 | 0% | $117 | 
Medium |
| Dental Cleaning - Child | $89 | 0% | $89 |
Medium |
| Dental Exam - Comprehensive | $98 | 0% | $98 |
Medium |
| Dental Exam - Periodic, Established Patient | $57 | 0% | $57 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $205 | 0% | $205 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $273 | 0% | $273 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $297 | 0% | $297 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $192 | 0% | $192 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $205 | 0% | $205 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $389 | 0% | $389 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $238 | 0% | $238 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $297 | 0% | $297 |
Medium |
| Flouride - Topical Varnish Application | $92 | 0% | $92 |
Medium |
| Fluoride - Topical Application | $46 | 0% | $46 |
Medium |
| Maintenance Therapy - Periodontal | $164 | 0% | $164 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $332 | 0% | $332 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $91 | 0% | $91 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | 0% | $68 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $193 | 0% | $193 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
Medium |
| X-Ray - Complete Intraoral Series | $161 | 0% | $161 |
Medium |
| X-Ray - Four Images, Bitewings | $76 | 0% | $76 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $59 | 0% | $59 |
Medium |
