| Dental Cleaning - Adult | $214 | 0% | $214 | 
Medium |
| Dental Cleaning - Child | $85 | 0% | $85 |
Medium |
| Dental Exam - Comprehensive | $99 | 0% | $99 |
Medium |
| Dental Exam - Periodic, Established Patient | $111 | 0% | $111 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $275 | 0% | $275 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $384 | 0% | $384 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $213 | 0% | $213 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $344 | 0% | $344 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $234 | 0% | $234 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $400 | 0% | $400 |
Medium |
| Flouride - Topical Varnish Application | $46 | 0% | $46 |
Medium |
| Maintenance Therapy - Periodontal | $302 | 0% | $302 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | 0% | $95 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $206 | 0% | $206 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
Medium |
| X-Ray - Complete Intraoral Series | $150 | 0% | $150 |
Medium |
| X-Ray - Four Images, Bitewings | $147 | 0% | $147 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
Medium |
| X-Ray - Two Images, Bitewings | $53 | 0% | $53 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $137 | 0% | $137 |
Medium |
