| Dental Cleaning - Adult | $126 | 0% | $126 | 
Medium |
| Dental Cleaning - Child | $89 | 0% | $89 |
Medium |
| Dental Exam - Comprehensive | $84 | 0% | $84 |
Medium |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $227 | 0% | $227 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | 0% | $221 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $249 | 0% | $249 |
Medium |
| Fluoride - Topical Application | $47 | 0% | $47 |
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 | $74 | 0% | $74 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $191 | 0% | $191 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $50 | 0% | $50 |
Medium |
| X-Ray - Complete Intraoral Series | $215 | 0% | $215 |
Medium |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $142 | 0% | $142 |
Medium |
