| Dental Cleaning - Adult | $106 | 0% | $106 | 
Medium |
| Dental Cleaning - Child | $85 | 0% | $85 |
Medium |
| Dental Exam - Comprehensive | $92 | 0% | $92 |
Medium |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $277 | 0% | $277 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $286 | 0% | $286 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $202 | 0% | $202 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $234 | 0% | $234 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $317 | 0% | $317 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $281 | 0% | $281 |
Medium |
| Flouride - Topical Varnish Application | $42 | 0% | $42 |
Medium |
| Maintenance Therapy - Periodontal | $165 | 0% | $165 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | 0% | $100 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $57 | 0% | $57 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $221 | 0% | $221 |
Medium |
| X-Ray - Four Images, Bitewings | $74 | 0% | $74 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $48 | 0% | $48 |
Medium |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $126 | 0% | $126 |
Medium |
