| Dental Cleaning - Adult | $151 | 0% | $151 | 
Medium |
| Dental Cleaning - Child | $83 | 0% | $83 |
Medium |
| Dental Exam - Comprehensive | $197 | 0% | $197 |
Medium |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $269 | 0% | $269 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $389 | 0% | $389 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $345 | 0% | $345 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $269 | 0% | $269 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $279 | 0% | $279 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $419 | 0% | $419 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $322 | 0% | $322 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $345 | 0% | $345 |
Medium |
| Flouride - Topical Varnish Application | $49 | 0% | $49 |
Medium |
| Fluoride - Topical Application | $50 | 0% | $50 |
Medium |
| Maintenance Therapy - Periodontal | $161 | 0% | $161 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $162 | 0% | $162 |
Medium |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $515 | 0% | $515 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $123 | 0% | $123 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $76 | 0% | $76 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $301 | 0% | $301 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $21 | 0% | $21 |
Medium |
| X-Ray - Complete Intraoral Series | $208 | 0% | $208 |
Medium |
| X-Ray - Four Images, Bitewings | $83 | 0% | $83 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | 0% | $36 |
Medium |
| X-Ray - Two Images, Bitewings | $58 | 0% | $58 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $135 | 0% | $135 |
Medium |
