| Dental Cleaning - Adult | $138 | 0% | $138 |
| Dental Cleaning - Child | $118 | 0% | $118 |
| Dental Exam - Comprehensive | $120 | 0% | $120 |
| Dental Exam - Periodic, Established Patient | $74 | 0% | $74 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $249 | 0% | $249 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $454 | 0% | $454 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $349 | 0% | $349 |
| Dental Filling - White (Resin): One Surface, Anterior | $218 | 0% | $218 |
| Dental Filling - White (Resin): One Surface, Posterior | $249 | 0% | $249 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $454 | 0% | $454 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $266 | 0% | $266 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $349 | 0% | $349 |
| Fluoride - Topical Application | $60 | 0% | $60 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $119 | 0% | $119 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $85 | 0% | $85 |
| Tooth Extraction - Elevation and/or Forceps Removal | $266 | 0% | $266 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | 0% | $36 |
| X-Ray - Complete Intraoral Series | $245 | 0% | $245 |
| X-Ray - Four Images, Bitewings | $99 | 0% | $99 |
| X-Ray - Intraoral, Periapical Radiographic Image | $43 | 0% | $43 |
| X-Ray - Two Images, Bitewings | $70 | 0% | $70 |
| X-Ray - Whole Mouth from Outside Mouth | $182 | 0% | $182 |
