| Dental Cleaning - Adult | $115 | 0% | $115 |
| Dental Cleaning - Child | $90 | 0% | $90 |
| Dental Exam - Comprehensive | $98 | 0% | $98 |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $230 | 0% | $230 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $297 | 0% | $297 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $237 | 0% | $237 |
| Dental Filling - White (Resin): One Surface, Posterior | $230 | 0% | $230 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $330 | 0% | $330 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $279 | 0% | $279 |
| Flouride - Topical Varnish Application | $50 | 0% | $50 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $98 | 0% | $98 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
| X-Ray - Complete Intraoral Series | $178 | 0% | $178 |
| X-Ray - Four Images, Bitewings | $80 | 0% | $80 |
| X-Ray - Intraoral, Periapical Radiographic Image | $71 | 0% | $71 |
| X-Ray - Two Images, Bitewings | $72 | 0% | $72 |
| X-Ray - Whole Mouth from Outside Mouth | $186 | 0% | $186 |
