| Dental Cleaning - Adult | $107 | 0% | $107 | 
Medium |
| Dental Cleaning - Child | $85 | 0% | $85 |
Medium |
| Dental Exam - Comprehensive | $91 | 0% | $91 |
Medium |
| Dental Exam - Periodic, Established Patient | $50 | 0% | $50 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $215 | 0% | $215 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $365 | 0% | $365 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $306 | 0% | $306 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $202 | 0% | $202 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $215 | 0% | $215 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $365 | 0% | $365 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $286 | 0% | $286 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $306 | 0% | $306 |
Medium |
| Flouride - Topical Varnish Application | $41 | 0% | $41 |
Medium |
| Maintenance Therapy - Periodontal | $150 | 0% | $150 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $66 | 0% | $66 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $307 | 0% | $307 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $97 | 0% | $97 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $452 | 0% | $452 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
Medium |
| X-Ray - Complete Intraoral Series | $149 | 0% | $149 |
Medium |
| X-Ray - Four Images, Bitewings | $109 | 0% | $109 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
Medium |
| X-Ray - Two Images, Bitewings | $72 | 0% | $72 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $131 | 0% | $131 |
Medium |
