| Dental Cleaning - Adult | $107 | 0% | $107 | 
Medium |
| Dental Cleaning - Child | $89 | 0% | $89 |
Medium |
| Dental Exam - Comprehensive | $103 | 0% | $103 |
Medium |
| Dental Exam - Periodic, Established Patient | $54 | 0% | $54 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $401 | 0% | $401 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $341 | 0% | $341 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $273 | 0% | $273 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $205 | 0% | $205 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $205 | 0% | $205 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $349 | 0% | $349 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $242 | 0% | $242 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $279 | 0% | $279 |
Medium |
| Flouride - Topical Varnish Application | $46 | 0% | $46 |
Medium |
| Maintenance Therapy - Periodontal | $167 | 0% | $167 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $294 | 0% | $294 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $93 | 0% | $93 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
Medium |
| X-Ray - Complete Intraoral Series | $168 | 0% | $168 |
Medium |
| X-Ray - Four Images, Bitewings | $79 | 0% | $79 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
Medium |
| X-Ray - Two Images, Bitewings | $51 | 0% | $51 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $139 | 0% | $139 |
Medium |
