| Dental Cleaning - Adult | $127 | 0% | $127 | 
Medium |
| Dental Cleaning - Child | $101 | 0% | $101 |
Medium |
| Dental Exam - Comprehensive | $118 | 0% | $118 |
Medium |
| Dental Exam - Periodic, Established Patient | $62 | 0% | $62 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $215 | 0% | $215 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $384 | 0% | $384 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $288 | 0% | $288 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $204 | 0% | $204 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $216 | 0% | $216 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $392 | 0% | $392 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $247 | 0% | $247 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $293 | 0% | $293 |
Medium |
| Flouride - Topical Varnish Application | $67 | 0% | $67 |
Medium |
| Fluoride - Topical Application | $51 | 0% | $51 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $68 | 0% | $68 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $109 | 0% | $109 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $70 | 0% | $70 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $209 | 0% | $209 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | 0% | $33 |
Medium |
| X-Ray - Complete Intraoral Series | $289 | 0% | $289 |
Medium |
| X-Ray - Four Images, Bitewings | $87 | 0% | $87 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
Medium |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $156 | 0% | $156 |
Medium |
