| Dental Cleaning - Adult | $189 | 0% | $189 | 
Medium |
| Dental Cleaning - Child | $145 | 0% | $145 |
Medium |
| Dental Exam - Comprehensive | $145 | 0% | $145 |
Medium |
| Dental Exam - Periodic, Established Patient | $88 | 0% | $88 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $209 | 0% | $209 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $352 | 0% | $352 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $309 | 0% | $309 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $194 | 0% | $194 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $209 | 0% | $209 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $473 | 0% | $473 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $313 | 0% | $313 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $389 | 0% | $389 |
Medium |
| Fluoride - Topical Application | $82 | 0% | $82 |
Medium |
| Maintenance Therapy - Periodontal | $212 | 0% | $212 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $137 | 0% | $137 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $97 | 0% | $97 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $260 | 0% | $260 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $21 | 0% | $21 |
Medium |
| X-Ray - Complete Intraoral Series | $265 | 0% | $265 |
Medium |
| X-Ray - Four Images, Bitewings | $113 | 0% | $113 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $61 | 0% | $61 |
Medium |
| X-Ray - Two Images, Bitewings | $92 | 0% | $92 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $223 | 0% | $223 |
Medium |
