F

OTHER RESTORATIVE SERVICES | January 1, 2026

PLACEMENT OF INTERIM DIRECT RESTORATION

RESIN-BASED COMPOSITE RESTORATIONS - DIRECT | RESTORATIVE | January 1, 2026

RESIN-BASED COMPOSITE – ONE SURFACE, POSTERIOR

AMALGAM RESTORATIONS (INCLUDING POLISHING) | January 1, 2026

AMALGAM – ONE SURFACE, PRIMARY OR PERMANENT

OTHER PREVENTIVE SERVICES | January 1, 2026

SEALANT – PER TOOTH

DENTAL PROPHYLAXIS | PREVENTIVE | January 1, 2026

PROPHYLAXIS – ADULT