| Dental Cleaning - Adult | $145 | 0% | $145 | 
Medium |
| Dental Cleaning - Child | $101 | 0% | $101 |
Medium |
| Dental Exam - Comprehensive | $116 | 0% | $116 |
Medium |
| Dental Exam - Periodic, Established Patient | $65 | 0% | $65 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $260 | 0% | $260 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $403 | 0% | $403 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $328 | 0% | $328 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $239 | 0% | $239 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $260 | 0% | $260 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $403 | 0% | $403 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | 0% | $271 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $328 | 0% | $328 |
Medium |
| Maintenance Therapy - Periodontal | $202 | 0% | $202 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $143 | 0% | $143 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $321 | 0% | $321 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | 0% | $103 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $101 | 0% | $101 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $284 | 0% | $284 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | 0% | $38 |
Medium |
| X-Ray - Complete Intraoral Series | $214 | 0% | $214 |
Medium |
| X-Ray - Four Images, Bitewings | $101 | 0% | $101 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $48 | 0% | $48 |
Medium |
| X-Ray - Two Images, Bitewings | $76 | 0% | $76 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $189 | 0% | $189 |
Medium |
