| Dental Cleaning - Adult | $145 | 0% | $145 | 
Medium |
| Dental Cleaning - Child | $106 | 0% | $106 |
Medium |
| Dental Exam - Periodic, Established Patient | $69 | 0% | $69 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $265 | 0% | $265 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $333 | 0% | $333 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $268 | 0% | $268 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $208 | 0% | $208 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | 0% | $221 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $300 | 0% | $300 |
Medium |
| Fluoride - Topical Application | $46 | 0% | $46 |
Medium |
| Maintenance Therapy - Periodontal | $182 | 0% | $182 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $109 | 0% | $109 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $100 | 0% | $100 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $251 | 0% | $251 |
Medium |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
Medium |
