| Dental Cleaning - Adult | $104 | 0% | $104 | 
Medium |
| Dental Cleaning - Child | $88 | 0% | $88 |
Medium |
| Dental Exam - Comprehensive | $100 | 0% | $100 |
Medium |
| Dental Exam - Periodic, Established Patient | $59 | 0% | $59 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $198 | 0% | $198 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $236 | 0% | $236 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $215 | 0% | $215 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $161 | 0% | $161 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $198 | 0% | $198 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $399 | 0% | $399 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $266 | 0% | $266 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $264 | 0% | $264 |
Medium |
| Flouride - Topical Varnish Application | $41 | 0% | $41 |
Medium |
| Maintenance Therapy - Periodontal | $142 | 0% | $142 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $272 | 0% | $272 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $104 | 0% | $104 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $54 | 0% | $54 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $168 | 0% | $168 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
Medium |
| X-Ray - Complete Intraoral Series | $149 | 0% | $149 |
Medium |
| X-Ray - Four Images, Bitewings | $72 | 0% | $72 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
Medium |
| X-Ray - Two Images, Bitewings | $51 | 0% | $51 |
Medium |
