| Dental Cleaning - Adult | $104 | 0% | $104 | 
Medium |
| Dental Cleaning - Child | $84 | 0% | $84 |
Medium |
| Dental Exam - Comprehensive | $95 | 0% | $95 |
Medium |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $188 | 0% | $188 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $412 | 0% | $412 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $261 | 0% | $261 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $173 | 0% | $173 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $188 | 0% | $188 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $340 | 0% | $340 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $205 | 0% | $205 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $261 | 0% | $261 |
Medium |
| Flouride - Topical Varnish Application | $41 | 0% | $41 |
Medium |
| Fluoride - Topical Application | $42 | 0% | $42 |
Medium |
| Maintenance Therapy - Periodontal | $150 | 0% | $150 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | 0% | $95 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | 0% | $68 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $205 | 0% | $205 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
Medium |
| X-Ray - Complete Intraoral Series | $208 | 0% | $208 |
Medium |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
Medium |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $213 | 0% | $213 |
Medium |
