| Dental Cleaning - Adult | $113 | 0% | $113 | 
Medium |
| Dental Cleaning - Child | $85 | 0% | $85 |
Medium |
| Dental Exam - Comprehensive | $105 | 0% | $105 |
Medium |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $194 | 0% | $194 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $334 | 0% | $334 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | 0% | $265 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $189 | 0% | $189 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $194 | 0% | $194 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | 0% | $342 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $226 | 0% | $226 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $268 | 0% | $268 |
Medium |
| Fluoride - Topical Application | $43 | 0% | $43 |
Medium |
| Maintenance Therapy - Periodontal | $152 | 0% | $152 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | 0% | $88 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $65 | 0% | $65 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $231 | 0% | $231 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
Medium |
| X-Ray - Complete Intraoral Series | $162 | 0% | $162 |
Medium |
| X-Ray - Four Images, Bitewings | $74 | 0% | $74 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $41 | 0% | $41 |
Medium |
| X-Ray - Two Images, Bitewings | $74 | 0% | $74 |
Medium |
