| Dental Cleaning - Adult | $105 | 0% | $105 | 
Medium |
| Dental Cleaning - Child | $101 | 0% | $101 |
Medium |
| Dental Exam - Comprehensive | $117 | 0% | $117 |
Medium |
| Dental Exam - Periodic, Established Patient | $61 | 0% | $61 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $203 | 0% | $203 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $265 | 0% | $265 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $216 | 0% | $216 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $208 | 0% | $208 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $236 | 0% | $236 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $404 | 0% | $404 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $239 | 0% | $239 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $311 | 0% | $311 |
Medium |
| Flouride - Topical Varnish Application | $61 | 0% | $61 |
Medium |
| Fluoride - Topical Application | $51 | 0% | $51 |
Medium |
| Maintenance Therapy - Periodontal | $149 | 0% | $149 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $68 | 0% | $68 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | 0% | $105 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | 0% | $69 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $221 | 0% | $221 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | 0% | $33 |
Medium |
| X-Ray - Complete Intraoral Series | $146 | 0% | $146 |
Medium |
| X-Ray - Four Images, Bitewings | $86 | 0% | $86 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
Medium |
| X-Ray - Two Images, Bitewings | $61 | 0% | $61 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $153 | 0% | $153 |
Medium |
