| Dental Cleaning - Adult | $147 | 0% | $147 | 
Medium |
| Dental Cleaning - Child | $118 | 0% | $118 |
Medium |
| Dental Exam - Comprehensive | $99 | 0% | $99 |
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 | $247 | 0% | $247 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $232 | 0% | $232 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $256 | 0% | $256 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $326 | 0% | $326 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $443 | 0% | $443 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $269 | 0% | $269 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $368 | 0% | $368 |
Medium |
| Flouride - Topical Varnish Application | $82 | 0% | $82 |
Medium |
| Maintenance Therapy - Periodontal | $206 | 0% | $206 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | 0% | $101 |
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 | $40 | 0% | $40 |
Medium |
| X-Ray - Complete Intraoral Series | $235 | 0% | $235 |
Medium |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $45 | 0% | $45 |
Medium |
