| Dental Cleaning - Adult | $126 | 0% | $126 | 
Medium |
| Dental Cleaning - Child | $97 | 0% | $97 |
Medium |
| Dental Exam - Comprehensive | $116 | 0% | $116 |
Medium |
| Dental Exam - Periodic, Established Patient | $68 | 0% | $68 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $265 | 0% | $265 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $362 | 0% | $362 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $308 | 0% | $308 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $215 | 0% | $215 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $265 | 0% | $265 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $368 | 0% | $368 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $235 | 0% | $235 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $308 | 0% | $308 |
Medium |
| Flouride - Topical Varnish Application | $58 | 0% | $58 |
Medium |
| Fluoride - Topical Application | $53 | 0% | $53 |
Medium |
| Maintenance Therapy - Periodontal | $185 | 0% | $185 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $58 | 0% | $58 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $102 | 0% | $102 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | 0% | $74 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $42 | 0% | $42 |
Medium |
| X-Ray - Complete Intraoral Series | $172 | 0% | $172 |
Medium |
| X-Ray - Four Images, Bitewings | $105 | 0% | $105 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $47 | 0% | $47 |
Medium |
| X-Ray - Two Images, Bitewings | $84 | 0% | $84 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $151 | 0% | $151 |
Medium |
