| Dental Cleaning - Adult | $164 | 0% | $164 | 
Medium |
| Dental Cleaning - Child | $62 | 0% | $62 |
Medium |
| Dental Exam - Comprehensive | $79 | 0% | $79 |
Medium |
| Dental Exam - Periodic, Established Patient | $42 | 0% | $42 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $150 | 0% | $150 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $214 | 0% | $214 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $192 | 0% | $192 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $143 | 0% | $143 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $150 | 0% | $150 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $433 | 0% | $433 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $188 | 0% | $188 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $389 | 0% | $389 |
Medium |
| Flouride - Topical Varnish Application | $42 | 0% | $42 |
Medium |
| Fluoride - Topical Application | $65 | 0% | $65 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $67 | 0% | $67 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $273 | 0% | $273 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $25 | 0% | $25 |
Medium |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $33 | 0% | $33 |
Medium |
| X-Ray - Two Images, Bitewings | $44 | 0% | $44 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $107 | 0% | $107 |
Medium |
