| Dental Cleaning - Adult | $126 | 0% | $126 | 
Medium |
| Dental Cleaning - Child | $89 | 0% | $89 |
Medium |
| Dental Exam - Comprehensive | $196 | 0% | $196 |
Medium |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $252 | 0% | $252 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $310 | 0% | $310 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $205 | 0% | $205 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $252 | 0% | $252 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $389 | 0% | $389 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $273 | 0% | $273 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $310 | 0% | $310 |
Medium |
| Flouride - Topical Varnish Application | $44 | 0% | $44 |
Medium |
| Maintenance Therapy - Periodontal | $158 | 0% | $158 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $110 | 0% | $110 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $158 | 0% | $158 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
Medium |
| X-Ray - Complete Intraoral Series | $179 | 0% | $179 |
Medium |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $42 | 0% | $42 |
Medium |
