| Dental Cleaning - Adult | $131 | 0% | $131 |
| Dental Cleaning - Child | $84 | 0% | $84 |
| Dental Exam - Periodic, Established Patient | $55 | 0% | $55 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $273 | 0% | $273 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $373 | 0% | $373 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $341 | 0% | $341 |
| Dental Filling - White (Resin): One Surface, Anterior | $263 | 0% | $263 |
| Dental Filling - White (Resin): One Surface, Posterior | $268 | 0% | $268 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $373 | 0% | $373 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $273 | 0% | $273 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $341 | 0% | $341 |
| Flouride - Topical Varnish Application | $42 | 0% | $42 |
| Maintenance Therapy - Periodontal | $152 | 0% | $152 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $131 | 0% | $131 |
| X-Ray - Complete Intraoral Series | $194 | 0% | $194 |
| X-Ray - Four Images, Bitewings | $89 | 0% | $89 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
| X-Ray - Two Images, Bitewings | $76 | 0% | $76 |
