| Dental Cleaning - Adult | $125 | 0% | $125 | 
Medium |
| Dental Cleaning - Child | $106 | 0% | $106 |
Medium |
| Dental Exam - Comprehensive | $110 | 0% | $110 |
Medium |
| Dental Exam - Periodic, Established Patient | $64 | 0% | $64 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $233 | 0% | $233 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $415 | 0% | $415 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $328 | 0% | $328 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $211 | 0% | $211 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $233 | 0% | $233 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $417 | 0% | $417 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $254 | 0% | $254 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $335 | 0% | $335 |
Medium |
| Flouride - Topical Varnish Application | $54 | 0% | $54 |
Medium |
| Fluoride - Topical Application | $54 | 0% | $54 |
Medium |
| Maintenance Therapy - Periodontal | $170 | 0% | $170 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $54 | 0% | $54 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $314 | 0% | $314 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $107 | 0% | $107 |
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 |
