| Dental Cleaning - Adult | $105 | 0% | $105 | 
Medium |
| Dental Cleaning - Child | $78 | 0% | $78 |
Medium |
| Dental Exam - Comprehensive | $121 | 0% | $121 |
Medium |
| Dental Exam - Periodic, Established Patient | $46 | 0% | $46 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $201 | 0% | $201 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $347 | 0% | $347 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $257 | 0% | $257 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $186 | 0% | $186 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $201 | 0% | $201 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $335 | 0% | $335 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $212 | 0% | $212 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $257 | 0% | $257 |
Medium |
| Flouride - Topical Varnish Application | $45 | 0% | $45 |
Medium |
| Fluoride - Topical Application | $33 | 0% | $33 |
Medium |
| Maintenance Therapy - Periodontal | $140 | 0% | $140 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $135 | 0% | $135 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $254 | 0% | $254 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $83 | 0% | $83 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $57 | 0% | $57 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $242 | 0% | $242 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
Medium |
| X-Ray - Complete Intraoral Series | $139 | 0% | $139 |
Medium |
| X-Ray - Four Images, Bitewings | $70 | 0% | $70 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
Medium |
| X-Ray - Two Images, Bitewings | $57 | 0% | $57 |
Medium |
