| Dental Cleaning - Adult | $124 | 0% | $124 | 
Medium |
| Dental Cleaning - Child | $95 | 0% | $95 |
Medium |
| Dental Exam - Comprehensive | $114 | 0% | $114 |
Medium |
| Dental Exam - Periodic, Established Patient | $81 | 0% | $81 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $221 | 0% | $221 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $284 | 0% | $284 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $223 | 0% | $223 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $355 | 0% | $355 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $284 | 0% | $284 |
Medium |
| Flouride - Topical Varnish Application | $57 | 0% | $57 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $99 | 0% | $99 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $81 | 0% | $81 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $216 | 0% | $216 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | 0% | $30 |
Medium |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
Medium |
| X-Ray - Two Images, Bitewings | $59 | 0% | $59 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $159 | 0% | $159 |
Medium |
