| Dental Cleaning - Adult | $128 | 0% | $128 | 
Medium |
| Dental Cleaning - Child | $109 | 0% | $109 |
Medium |
| Dental Exam - Comprehensive | $112 | 0% | $112 |
Medium |
| Dental Exam - Periodic, Established Patient | $65 | 0% | $65 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $233 | 0% | $233 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $417 | 0% | $417 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $335 | 0% | $335 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $219 | 0% | $219 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $236 | 0% | $236 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $417 | 0% | $417 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $255 | 0% | $255 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $336 | 0% | $336 |
Medium |
| Flouride - Topical Varnish Application | $54 | 0% | $54 |
Medium |
| Fluoride - Topical Application | $54 | 0% | $54 |
Medium |
| Maintenance Therapy - Periodontal | $173 | 0% | $173 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $62 | 0% | $62 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $330 | 0% | $330 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $109 | 0% | $109 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $76 | 0% | $76 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $243 | 0% | $243 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $51 | 0% | $51 |
Medium |
| X-Ray - Complete Intraoral Series | $181 | 0% | $181 |
Medium |
| X-Ray - Four Images, Bitewings | $97 | 0% | $97 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $57 | 0% | $57 |
Medium |
| X-Ray - Two Images, Bitewings | $72 | 0% | $72 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $172 | 0% | $172 |
Medium |
