| Dental Cleaning - Adult | $105 | 0% | $105 | 
Medium |
| Dental Cleaning - Child | $85 | 0% | $85 |
Medium |
| Dental Exam - Comprehensive | $90 | 0% | $90 |
Medium |
| Dental Exam - Periodic, Established Patient | $55 | 0% | $55 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $162 | 0% | $162 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $487 | 0% | $487 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $196 | 0% | $196 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $162 | 0% | $162 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $302 | 0% | $302 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $306 | 0% | $306 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $256 | 0% | $256 |
Medium |
| Fluoride - Topical Application | $48 | 0% | $48 |
Medium |
| Maintenance Therapy - Periodontal | $307 | 0% | $307 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | 0% | $88 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $194 | 0% | $194 |
Medium |
| X-Ray - Complete Intraoral Series | $167 | 0% | $167 |
Medium |
| X-Ray - Four Images, Bitewings | $76 | 0% | $76 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $57 | 0% | $57 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $137 | 0% | $137 |
Medium |
