| Dental Cleaning - Adult | $116 | 0% | $116 | 
Medium |
| Dental Exam - Comprehensive | $120 | 0% | $120 |
Medium |
| Dental Exam - Periodic, Established Patient | $61 | 0% | $61 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $243 | 0% | $243 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $386 | 0% | $386 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $309 | 0% | $309 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $204 | 0% | $204 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $250 | 0% | $250 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $398 | 0% | $398 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $309 | 0% | $309 |
Medium |
| Maintenance Therapy - Periodontal | $342 | 0% | $342 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $158 | 0% | $158 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $107 | 0% | $107 |
Medium |
| X-Ray - Complete Intraoral Series | $182 | 0% | $182 |
Medium |
| X-Ray - Four Images, Bitewings | $95 | 0% | $95 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $43 | 0% | $43 |
Medium |
