| Dental Cleaning - Adult | $121 | 0% | $121 | 
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 | $231 | 0% | $231 |
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 |
| Maintenance Therapy - Periodontal | $147 | 0% | $147 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $143 | 0% | $143 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $244 | 0% | $244 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $98 | 0% | $98 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
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 | $69 | 0% | $69 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
Medium |
| X-Ray - Two Images, Bitewings | $40 | 0% | $40 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $121 | 0% | $121 |
Medium |
