| Dental Cleaning - Adult | $131 | 0% | $131 | 
Medium |
| Dental Cleaning - Child | $101 | 0% | $101 |
Medium |
| Dental Exam - Comprehensive | $126 | 0% | $126 |
Medium |
| Dental Exam - Periodic, Established Patient | $61 | 0% | $61 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $265 | 0% | $265 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $457 | 0% | $457 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $336 | 0% | $336 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $232 | 0% | $232 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $257 | 0% | $257 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $457 | 0% | $457 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $319 | 0% | $319 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $336 | 0% | $336 |
Medium |
| Flouride - Topical Varnish Application | $53 | 0% | $53 |
Medium |
| Maintenance Therapy - Periodontal | $184 | 0% | $184 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $357 | 0% | $357 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $147 | 0% | $147 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $76 | 0% | $76 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $249 | 0% | $249 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
Medium |
| X-Ray - Complete Intraoral Series | $206 | 0% | $206 |
Medium |
| X-Ray - Four Images, Bitewings | $89 | 0% | $89 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $29 | 0% | $29 |
Medium |
| X-Ray - Two Images, Bitewings | $60 | 0% | $60 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $200 | 0% | $200 |
Medium |
