| Dental Cleaning - Adult | $112 | 0% | $112 | 
Medium |
| Dental Exam - Comprehensive | $99 | 0% | $99 |
Medium |
| Dental Exam - Periodic, Established Patient | $69 | 0% | $69 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $215 | 0% | $215 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $370 | 0% | $370 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $300 | 0% | $300 |
Medium |
| Flouride - Topical Varnish Application | $99 | 0% | $99 |
Medium |
| Fluoride - Topical Application | $71 | 0% | $71 |
Medium |
| Maintenance Therapy - Periodontal | $193 | 0% | $193 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $315 | 0% | $315 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | 0% | $101 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $17 | 0% | $17 |
Medium |
| X-Ray - Complete Intraoral Series | $197 | 0% | $197 |
Medium |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
Medium |
