| Dental Cleaning - Adult | $133 | 0% | $133 | 
Medium |
| Dental Cleaning - Child | $109 | 0% | $109 |
Medium |
| Dental Exam - Comprehensive | $111 | 0% | $111 |
Medium |
| Dental Exam - Periodic, Established Patient | $70 | 0% | $70 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $233 | 0% | $233 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $355 | 0% | $355 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $299 | 0% | $299 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $201 | 0% | $201 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $233 | 0% | $233 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $355 | 0% | $355 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $247 | 0% | $247 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $299 | 0% | $299 |
Medium |
| Flouride - Topical Varnish Application | $43 | 0% | $43 |
Medium |
| Fluoride - Topical Application | $43 | 0% | $43 |
Medium |
| Maintenance Therapy - Periodontal | $181 | 0% | $181 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $350 | 0% | $350 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $110 | 0% | $110 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $225 | 0% | $225 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
Medium |
| X-Ray - Complete Intraoral Series | $173 | 0% | $173 |
Medium |
| X-Ray - Four Images, Bitewings | $82 | 0% | $82 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $41 | 0% | $41 |
Medium |
| X-Ray - Two Images, Bitewings | $64 | 0% | $64 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $153 | 0% | $153 |
Medium |
