| Dental Cleaning - Adult | $116 | 0% | $116 | 
Medium |
| Dental Cleaning - Child | $90 | 0% | $90 |
Medium |
| Dental Exam - Comprehensive | $101 | 0% | $101 |
Medium |
| Dental Exam - Periodic, Established Patient | $54 | 0% | $54 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $182 | 0% | $182 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $360 | 0% | $360 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $193 | 0% | $193 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $170 | 0% | $170 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $218 | 0% | $218 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $351 | 0% | $351 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $218 | 0% | $218 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $272 | 0% | $272 |
Medium |
| Fluoride - Topical Application | $49 | 0% | $49 |
Medium |
| Maintenance Therapy - Periodontal | $150 | 0% | $150 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $51 | 0% | $51 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $90 | 0% | $90 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | 0% | $59 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
Medium |
| X-Ray - Complete Intraoral Series | $164 | 0% | $164 |
Medium |
| X-Ray - Four Images, Bitewings | $82 | 0% | $82 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
Medium |
| X-Ray - Two Images, Bitewings | $54 | 0% | $54 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $153 | 0% | $153 |
Medium |
