| Dental Cleaning - Adult | $121 | 0% | $121 | 
Medium |
| Dental Cleaning - Child | $92 | 0% | $92 |
Medium |
| Dental Exam - Comprehensive | $118 | 0% | $118 |
Medium |
| Dental Exam - Periodic, Established Patient | $68 | 0% | $68 |
Medium |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $243 | 0% | $243 |
Medium |
| Dental Filling - White (Resin): One Surface, Anterior | $223 | 0% | $223 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $273 | 0% | $273 |
Medium |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $299 | 0% | $299 |
Medium |
| Flouride - Topical Varnish Application | $58 | 0% | $58 |
Medium |
| Fluoride - Topical Application | $58 | 0% | $58 |
Medium |
| Maintenance Therapy - Periodontal | $177 | 0% | $177 |
Medium |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $107 | 0% | $107 |
Medium |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | 0% | $74 |
Medium |
| X-Ray - Complete Intraoral Series | $176 | 0% | $176 |
Medium |
| X-Ray - Four Images, Bitewings | $88 | 0% | $88 |
Medium |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
Medium |
| X-Ray - Two Images, Bitewings | $61 | 0% | $61 |
Medium |
