| Dental Cleaning - Adult | $102 | 0% | $102 |
| Dental Cleaning - Child | $83 | 0% | $83 |
| Dental Exam - Comprehensive | $84 | 0% | $84 |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $194 | 0% | $194 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $315 | 0% | $315 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | 0% | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $173 | 0% | $173 |
| Dental Filling - White (Resin): One Surface, Posterior | $194 | 0% | $194 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $315 | 0% | $315 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $210 | 0% | $210 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
| Flouride - Topical Varnish Application | $47 | 0% | $47 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $84 | 0% | $84 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $53 | 0% | $53 |
| X-Ray - Complete Intraoral Series | $142 | 0% | $142 |
| X-Ray - Four Images, Bitewings | $72 | 0% | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
| X-Ray - Two Images, Bitewings | $49 | 0% | $49 |
| X-Ray - Whole Mouth from Outside Mouth | $140 | 0% | $140 |
