| Dental Cleaning - Adult | $105 | 0% | $105 | 
Medium |
| Dental Cleaning - Child | $81 | 0% | $81 |
Medium |
| Dental Exam - Comprehensive | $102 | 0% | $102 |
Medium |
| Dental Exam - Periodic, Established Patient | $54 | 0% | $54 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $168 | 0% | $168 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $259 | 0% | $259 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $210 | 0% | $210 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | 0% | $184 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $216 | 0% | $216 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | 0% | $342 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $237 | 0% | $237 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $273 | 0% | $273 |
Medium |
| Flouride - Topical Varnish Application | $44 | 0% | $44 |
Medium |
| Fluoride - Topical Application | $43 | 0% | $43 |
Medium |
| Maintenance Therapy - Periodontal | $300 | 0% | $300 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $187 | 0% | $187 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
Medium |
| X-Ray - Complete Intraoral Series | $153 | 0% | $153 |
Medium |
| X-Ray - Four Images, Bitewings | $76 | 0% | $76 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
Medium |
| X-Ray - Two Images, Bitewings | $54 | 0% | $54 |
Medium |
