| Dental Cleaning - Adult | $137 | 0% | $137 | 
Medium |
| Dental Cleaning - Child | $116 | 0% | $116 |
Medium |
| Dental Exam - Comprehensive | $129 | 0% | $129 |
Medium |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $278 | 0% | $278 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $383 | 0% | $383 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $331 | 0% | $331 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $278 | 0% | $278 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $278 | 0% | $278 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $368 | 0% | $368 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $331 | 0% | $331 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $331 | 0% | $331 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $102 | 0% | $102 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | 0% | $61 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $263 | 0% | $263 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
Medium |
| X-Ray - Complete Intraoral Series | $173 | 0% | $173 |
Medium |
| X-Ray - Four Images, Bitewings | $89 | 0% | $89 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
Medium |
| X-Ray - Two Images, Bitewings | $68 | 0% | $68 |
Medium |
