| Dental Cleaning - Adult | $131 | 0% | $131 | 
Medium |
| Dental Cleaning - Child | $110 | 0% | $110 |
Medium |
| Dental Exam - Comprehensive | $121 | 0% | $121 |
Medium |
| Dental Exam - Periodic, Established Patient | $69 | 0% | $69 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $236 | 0% | $236 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $420 | 0% | $420 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $331 | 0% | $331 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $223 | 0% | $223 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $236 | 0% | $236 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $433 | 0% | $433 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $247 | 0% | $247 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $331 | 0% | $331 |
Medium |
| Flouride - Topical Varnish Application | $58 | 0% | $58 |
Medium |
| Fluoride - Topical Application | $63 | 0% | $63 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $82 | 0% | $82 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $116 | 0% | $116 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $79 | 0% | $79 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $236 | 0% | $236 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $42 | 0% | $42 |
Medium |
| X-Ray - Complete Intraoral Series | $260 | 0% | $260 |
Medium |
| X-Ray - Four Images, Bitewings | $95 | 0% | $95 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $47 | 0% | $47 |
Medium |
| X-Ray - Two Images, Bitewings | $68 | 0% | $68 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $168 | 0% | $168 |
Medium |
