| Dental Cleaning - Adult | $114 | 0% | $114 | 
Medium |
| Dental Cleaning - Child | $81 | 0% | $81 |
Medium |
| Dental Exam - Comprehensive | $92 | 0% | $92 |
Medium |
| Dental Exam - Periodic, Established Patient | $56 | 0% | $56 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $195 | 0% | $195 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $309 | 0% | $309 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $261 | 0% | $261 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $191 | 0% | $191 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $205 | 0% | $205 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $324 | 0% | $324 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $221 | 0% | $221 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $261 | 0% | $261 |
Medium |
| Flouride - Topical Varnish Application | $49 | 0% | $49 |
Medium |
| Maintenance Therapy - Periodontal | $153 | 0% | $153 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $288 | 0% | $288 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $79 | 0% | $79 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $192 | 0% | $192 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
Medium |
| X-Ray - Complete Intraoral Series | $213 | 0% | $213 |
Medium |
| X-Ray - Four Images, Bitewings | $70 | 0% | $70 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
Medium |
| X-Ray - Two Images, Bitewings | $49 | 0% | $49 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $150 | 0% | $150 |
Medium |
