| Dental Cleaning - Adult | $108 | 0% | $108 | 
Medium |
| Dental Cleaning - Child | $118 | 0% | $118 |
Medium |
| Dental Exam - Comprehensive | $116 | 0% | $116 |
Medium |
| Dental Exam - Periodic, Established Patient | $69 | 0% | $69 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $185 | 0% | $185 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $324 | 0% | $324 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | 0% | $221 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $370 | 0% | $370 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $265 | 0% | $265 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $300 | 0% | $300 |
Medium |
| Flouride - Topical Varnish Application | $55 | 0% | $55 |
Medium |
| Maintenance Therapy - Periodontal | $193 | 0% | $193 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | 0% | $101 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $67 | 0% | $67 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $191 | 0% | $191 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $24 | 0% | $24 |
Medium |
| X-Ray - Complete Intraoral Series | $197 | 0% | $197 |
Medium |
| X-Ray - Four Images, Bitewings | $83 | 0% | $83 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $163 | 0% | $163 |
Medium |
