| Dental Cleaning - Adult | $145 | 0% | $145 | 
Medium |
| Dental Cleaning - Child | $118 | 0% | $118 |
Medium |
| Dental Exam - Comprehensive | $126 | 0% | $126 |
Medium |
| Dental Exam - Periodic, Established Patient | $69 | 0% | $69 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $185 | 0% | $185 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $374 | 0% | $374 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $294 | 0% | $294 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | 0% | $221 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $370 | 0% | $370 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $300 | 0% | $300 |
Medium |
| Fluoride - Topical Application | $71 | 0% | $71 |
Medium |
| Maintenance Therapy - Periodontal | $193 | 0% | $193 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $51 | 0% | $51 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $341 | 0% | $341 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | 0% | $101 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
Medium |
| X-Ray - Complete Intraoral Series | $184 | 0% | $184 |
Medium |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
Medium |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
Medium |
