| Dental Cleaning - Adult | $109 | 0% | $109 | 
Medium |
| Dental Cleaning - Child | $76 | 0% | $76 |
Medium |
| Dental Exam - Comprehensive | $106 | 0% | $106 |
Medium |
| Dental Exam - Periodic, Established Patient | $62 | 0% | $62 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $180 | 0% | $180 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $261 | 0% | $261 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $224 | 0% | $224 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $205 | 0% | $205 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $212 | 0% | $212 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $364 | 0% | $364 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $250 | 0% | $250 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $303 | 0% | $303 |
Medium |
| Flouride - Topical Varnish Application | $44 | 0% | $44 |
Medium |
| Maintenance Therapy - Periodontal | $150 | 0% | $150 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $107 | 0% | $107 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $298 | 0% | $298 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $98 | 0% | $98 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $66 | 0% | $66 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $268 | 0% | $268 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
Medium |
| X-Ray - Complete Intraoral Series | $173 | 0% | $173 |
Medium |
| X-Ray - Four Images, Bitewings | $77 | 0% | $77 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | 0% | $36 |
Medium |
| X-Ray - Two Images, Bitewings | $55 | 0% | $55 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $173 | 0% | $173 |
Medium |
