| Dental Cleaning - Child | $118 | 0% | $118 | 
Medium |
| Dental Exam - Comprehensive | $165 | 0% | $165 |
Medium |
| Dental Exam - Periodic, Established Patient | $81 | 0% | $81 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $336 | 0% | $336 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $263 | 0% | $263 |
Medium |
| Flouride - Topical Varnish Application | $86 | 0% | $86 |
Medium |
| Fluoride - Topical Application | $86 | 0% | $86 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $160 | 0% | $160 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $100 | 0% | $100 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $263 | 0% | $263 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $61 | 0% | $61 |
Medium |
| X-Ray - Four Images, Bitewings | $106 | 0% | $106 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $61 | 0% | $61 |
Medium |
| X-Ray - Two Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $186 | 0% | $186 |
Medium |
