| Dental Cleaning - Adult | $113 | 0% | $113 | 
Medium |
| Dental Cleaning - Child | $113 | 0% | $113 |
Medium |
| Dental Exam - Comprehensive | $120 | 0% | $120 |
Medium |
| Dental Exam - Periodic, Established Patient | $40 | 0% | $40 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $205 | 0% | $205 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | 0% | $326 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | 0% | $265 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $212 | 0% | $212 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $233 | 0% | $233 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | 0% | $342 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $216 | 0% | $216 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $245 | 0% | $245 |
Medium |
| Flouride - Topical Varnish Application | $59 | 0% | $59 |
Medium |
| Fluoride - Topical Application | $48 | 0% | $48 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $68 | 0% | $68 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $80 | 0% | $80 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $260 | 0% | $260 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $39 | 0% | $39 |
Medium |
| X-Ray - Complete Intraoral Series | $144 | 0% | $144 |
Medium |
| X-Ray - Four Images, Bitewings | $92 | 0% | $92 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
Medium |
| X-Ray - Two Images, Bitewings | $59 | 0% | $59 |
Medium |
