| Dental Cleaning - Adult | $137 | 0% | $137 | 
Medium |
| Dental Cleaning - Child | $105 | 0% | $105 |
Medium |
| Dental Exam - Comprehensive | $108 | 0% | $108 |
Medium |
| Dental Exam - Periodic, Established Patient | $95 | 0% | $95 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $289 | 0% | $289 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $236 | 0% | $236 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $247 | 0% | $247 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $704 | 0% | $704 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $272 | 0% | $272 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $278 | 0% | $278 |
Medium |
| Fluoride - Topical Application | $78 | 0% | $78 |
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 | $79 | 0% | $79 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $236 | 0% | $236 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $45 | 0% | $45 |
Medium |
| X-Ray - Complete Intraoral Series | $212 | 0% | $212 |
Medium |
| X-Ray - Four Images, Bitewings | $126 | 0% | $126 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $56 | 0% | $56 |
Medium |
| X-Ray - Two Images, Bitewings | $101 | 0% | $101 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $236 | 0% | $236 |
Medium |
