| Dental Cleaning - Adult | $107 | 0% | $107 | 
Medium |
| Dental Cleaning - Child | $79 | 0% | $79 |
Medium |
| Dental Exam - Comprehensive | $100 | 0% | $100 |
Medium |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $194 | 0% | $194 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $315 | 0% | $315 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $231 | 0% | $231 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | 0% | $184 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $194 | 0% | $194 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $315 | 0% | $315 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $210 | 0% | $210 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $231 | 0% | $231 |
Medium |
| Fluoride - Topical Application | $39 | 0% | $39 |
Medium |
| Maintenance Therapy - Periodontal | $151 | 0% | $151 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $51 | 0% | $51 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $273 | 0% | $273 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $79 | 0% | $79 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $231 | 0% | $231 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | 0% | $38 |
Medium |
| X-Ray - Complete Intraoral Series | $146 | 0% | $146 |
Medium |
| X-Ray - Four Images, Bitewings | $79 | 0% | $79 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
Medium |
| X-Ray - Two Images, Bitewings | $56 | 0% | $56 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $142 | 0% | $142 |
Medium |
