| Dental Cleaning - Adult | $189 | 0% | $189 | 
Medium |
| Dental Cleaning - Child | $168 | 0% | $168 |
Medium |
| Dental Exam - Comprehensive | $113 | 0% | $113 |
Medium |
| Dental Exam - Periodic, Established Patient | $82 | 0% | $82 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $276 | 0% | $276 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $209 | 0% | $209 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $329 | 0% | $329 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $276 | 0% | $276 |
Medium |
| Maintenance Therapy - Periodontal | $176 | 0% | $176 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $305 | 0% | $305 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $130 | 0% | $130 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $319 | 0% | $319 |
Medium |
| X-Ray - Four Images, Bitewings | $130 | 0% | $130 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $57 | 0% | $57 |
Medium |
