| Dental Cleaning - Adult | $105 | 0% | $105 | 
Medium |
| Dental Cleaning - Child | $74 | 0% | $74 |
Medium |
| Dental Exam - Comprehensive | $168 | 0% | $168 |
Medium |
| Dental Exam - Periodic, Established Patient | $44 | 0% | $44 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $197 | 0% | $197 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $415 | 0% | $415 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $284 | 0% | $284 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $197 | 0% | $197 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $197 | 0% | $197 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $415 | 0% | $415 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $252 | 0% | $252 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $284 | 0% | $284 |
Medium |
| Flouride - Topical Varnish Application | $38 | 0% | $38 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $143 | 0% | $143 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $200 | 0% | $200 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $47 | 0% | $47 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $22 | 0% | $22 |
Medium |
| X-Ray - Complete Intraoral Series | $175 | 0% | $175 |
Medium |
| X-Ray - Four Images, Bitewings | $109 | 0% | $109 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $26 | 0% | $26 |
Medium |
| X-Ray - Two Images, Bitewings | $40 | 0% | $40 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $121 | 0% | $121 |
Medium |
