| Dental Cleaning - Adult | $126 | 0% | $126 | 
Medium |
| Dental Cleaning - Child | $105 | 0% | $105 |
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 | $226 | 0% | $226 |
Medium |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $408 | 0% | $408 |
Medium |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | 0% | $265 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $200 | 0% | $200 |
Medium |
| Dental Filling - White (Resin): One Surface, Posterior | $231 | 0% | $231 |
Medium |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $391 | 0% | $391 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $242 | 0% | $242 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $315 | 0% | $315 |
Medium |
| Flouride - Topical Varnish Application | $53 | 0% | $53 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $56 | 0% | $56 |
Medium |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $106 | 0% | $106 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | 0% | $69 |
Medium |
| Tooth Extraction - Elevation and/or Forceps Removal | $218 | 0% | $218 |
Medium |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | 0% | $33 |
Medium |
| X-Ray - Complete Intraoral Series | $179 | 0% | $179 |
Medium |
| X-Ray - Four Images, Bitewings | $86 | 0% | $86 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
Medium |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
Medium |
| X-Ray - Whole Mouth from Outside Mouth | $158 | 0% | $158 |
Medium |
