| Dental Cleaning - Adult | $137 | 0% | $137 | 
Medium |
| Dental Cleaning - Child | $105 | 0% | $105 |
Medium |
| Dental Exam - Comprehensive | $101 | 0% | $101 |
Medium |
| Dental Exam - Periodic, Established Patient | $74 | 0% | $74 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $210 | 0% | $210 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $294 | 0% | $294 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $231 | 0% | $231 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $358 | 0% | $358 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $294 | 0% | $294 |
Medium |
| Flouride - Topical Varnish Application | $63 | 0% | $63 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $51 | 0% | $51 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $158 | 0% | $158 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $79 | 0% | $79 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $210 | 0% | $210 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
Medium |
| X-Ray - Complete Intraoral Series | $242 | 0% | $242 |
Medium |
| X-Ray - Four Images, Bitewings | $105 | 0% | $105 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
Medium |
| X-Ray - Two Images, Bitewings | $68 | 0% | $68 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $191 | 0% | $191 |
Medium |
