| Dental Cleaning - Adult | $121 | 0% | $121 | 
Medium |
| Dental Cleaning - Child | $101 | 0% | $101 |
Medium |
| Dental Exam - Comprehensive | $108 | 0% | $108 |
Medium |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $279 | 0% | $279 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $423 | 0% | $423 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $360 | 0% | $360 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $285 | 0% | $285 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $279 | 0% | $279 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $436 | 0% | $436 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $309 | 0% | $309 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $360 | 0% | $360 |
Medium |
| Flouride - Topical Varnish Application | $49 | 0% | $49 |
Medium |
| Maintenance Therapy - Periodontal | $173 | 0% | $173 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $160 | 0% | $160 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $319 | 0% | $319 |
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 | $79 | 0% | $79 |
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 | $37 | 0% | $37 |
Medium |
| X-Ray - Complete Intraoral Series | $173 | 0% | $173 |
Medium |
| X-Ray - Four Images, Bitewings | $86 | 0% | $86 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
Medium |
| X-Ray - Two Images, Bitewings | $62 | 0% | $62 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $168 | 0% | $168 |
Medium |
