| Dental Cleaning - Adult | $122 | 0% | $122 | 
Medium |
| Dental Cleaning - Child | $92 | 0% | $92 |
Medium |
| Dental Exam - Comprehensive | $90 | 0% | $90 |
Medium |
| Dental Exam - Periodic, Established Patient | $46 | 0% | $46 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $182 | 0% | $182 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $318 | 0% | $318 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $231 | 0% | $231 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $174 | 0% | $174 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $318 | 0% | $318 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $275 | 0% | $275 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $307 | 0% | $307 |
Medium |
| Flouride - Topical Varnish Application | $55 | 0% | $55 |
Medium |
| Maintenance Therapy - Periodontal | $171 | 0% | $171 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $301 | 0% | $301 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | 0% | $103 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $73 | 0% | $73 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $189 | 0% | $189 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $23 | 0% | $23 |
Medium |
| X-Ray - Complete Intraoral Series | $182 | 0% | $182 |
Medium |
| X-Ray - Four Images, Bitewings | $83 | 0% | $83 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $30 | 0% | $30 |
Medium |
| X-Ray - Two Images, Bitewings | $46 | 0% | $46 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $153 | 0% | $153 |
Medium |
