| Dental Cleaning - Adult | $129 | 0% | $129 | 
Medium |
| Dental Cleaning - Child | $105 | 0% | $105 |
Medium |
| Dental Exam - Comprehensive | $129 | 0% | $129 |
Medium |
| Dental Exam - Periodic, Established Patient | $66 | 0% | $66 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $242 | 0% | $242 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $415 | 0% | $415 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $339 | 0% | $339 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $231 | 0% | $231 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $242 | 0% | $242 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $415 | 0% | $415 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $282 | 0% | $282 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $339 | 0% | $339 |
Medium |
| Flouride - Topical Varnish Application | $57 | 0% | $57 |
Medium |
| Fluoride - Topical Application | $56 | 0% | $56 |
Medium |
| Maintenance Therapy - Periodontal | $189 | 0% | $189 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $276 | 0% | $276 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $113 | 0% | $113 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $75 | 0% | $75 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | 0% | $184 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | 0% | $38 |
Medium |
| X-Ray - Complete Intraoral Series | $189 | 0% | $189 |
Medium |
| X-Ray - Four Images, Bitewings | $105 | 0% | $105 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $45 | 0% | $45 |
Medium |
| X-Ray - Two Images, Bitewings | $67 | 0% | $67 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $148 | 0% | $148 |
Medium |
