| Dental Cleaning - Adult | $116 | 0% | $116 | 
Medium |
| Dental Cleaning - Child | $88 | 0% | $88 |
Medium |
| Dental Exam - Comprehensive | $105 | 0% | $105 |
Medium |
| Dental Exam - Periodic, Established Patient | $56 | 0% | $56 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $237 | 0% | $237 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $347 | 0% | $347 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $298 | 0% | $298 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $243 | 0% | $243 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $347 | 0% | $347 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $273 | 0% | $273 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $284 | 0% | $284 |
Medium |
| Fluoride - Topical Application | $49 | 0% | $49 |
Medium |
| Maintenance Therapy - Periodontal | $171 | 0% | $171 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $596 | 0% | $596 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | 0% | $95 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $66 | 0% | $66 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $210 | 0% | $210 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
Medium |
| X-Ray - Complete Intraoral Series | $154 | 0% | $154 |
Medium |
| X-Ray - Four Images, Bitewings | $78 | 0% | $78 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
Medium |
| X-Ray - Two Images, Bitewings | $105 | 0% | $105 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $150 | 0% | $150 |
Medium |
