| Dental Cleaning - Adult | $117 | 0% | $117 |
| Dental Cleaning - Child | $91 | 0% | $91 |
| Dental Exam - Comprehensive | $148 | 0% | $148 |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $363 | 0% | $363 |
| Dental Filling - White (Resin): One Surface, Anterior | $204 | 0% | $204 |
| Dental Filling - White (Resin): One Surface, Posterior | $222 | 0% | $222 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $374 | 0% | $374 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $245 | 0% | $245 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $586 | 0% | $586 |
| Fluoride - Topical Application | $55 | 0% | $55 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $96 | 0% | $96 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $40 | 0% | $40 |
| X-Ray - Complete Intraoral Series | $330 | 0% | $330 |
| X-Ray - Four Images, Bitewings | $92 | 0% | $92 |
| X-Ray - Intraoral, Periapical Radiographic Image | $41 | 0% | $41 |
| X-Ray - Two Images, Bitewings | $60 | 0% | $60 |
