| Dental Cleaning - Adult | $122 | 0% | $122 | 
Medium |
| Dental Cleaning - Child | $90 | 0% | $90 |
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 | $166 | 0% | $166 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $223 | 0% | $223 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $167 | 0% | $167 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $195 | 0% | $195 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $318 | 0% | $318 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $260 | 0% | $260 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $294 | 0% | $294 |
Medium |
| Flouride - Topical Varnish Application | $51 | 0% | $51 |
Medium |
| Maintenance Therapy - Periodontal | $167 | 0% | $167 |
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 | $101 | 0% | $101 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | 0% | $71 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $19 | 0% | $19 |
Medium |
| X-Ray - Complete Intraoral Series | $182 | 0% | $182 |
Medium |
| X-Ray - Four Images, Bitewings | $80 | 0% | $80 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $30 | 0% | $30 |
Medium |
| X-Ray - Two Images, Bitewings | $44 | 0% | $44 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $156 | 0% | $156 |
Medium |
