| Dental Cleaning - Adult | $142 | 0% | $142 | 
Medium |
| Dental Cleaning - Child | $121 | 0% | $121 |
Medium |
| Dental Exam - Comprehensive | $108 | 0% | $108 |
Medium |
| Dental Exam - Periodic, Established Patient | $98 | 0% | $98 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $289 | 0% | $289 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $313 | 0% | $313 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $242 | 0% | $242 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $289 | 0% | $289 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $357 | 0% | $357 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $278 | 0% | $278 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $310 | 0% | $310 |
Medium |
| Fluoride - Topical Application | $79 | 0% | $79 |
Medium |
| Maintenance Therapy - Periodontal | $184 | 0% | $184 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $104 | 0% | $104 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $83 | 0% | $83 |
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 | $49 | 0% | $49 |
Medium |
| X-Ray - Complete Intraoral Series | $226 | 0% | $226 |
Medium |
| X-Ray - Four Images, Bitewings | $131 | 0% | $131 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $58 | 0% | $58 |
Medium |
| X-Ray - Two Images, Bitewings | $104 | 0% | $104 |
Medium |
