| Dental Cleaning - Adult | $90 | 0% | $90 |
| Dental Cleaning - Child | $122 | 0% | $122 |
| Dental Exam - Comprehensive | $126 | 0% | $126 |
| Dental Exam - Periodic, Established Patient | $38 | 0% | $38 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $155 | 0% | $155 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $280 | 0% | $280 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $215 | 0% | $215 |
| Dental Filling - White (Resin): One Surface, Anterior | $138 | 0% | $138 |
| Dental Filling - White (Resin): One Surface, Posterior | $155 | 0% | $155 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $280 | 0% | $280 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $169 | 0% | $169 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $215 | 0% | $215 |
| Fluoride - Topical Application | $37 | 0% | $37 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $77 | 0% | $77 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $49 | 0% | $49 |
| Tooth Extraction - Elevation and/or Forceps Removal | $299 | 0% | $299 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $40 | 0% | $40 |
| X-Ray - Complete Intraoral Series | $132 | 0% | $132 |
| X-Ray - Four Images, Bitewings | $60 | 0% | $60 |
| X-Ray - Intraoral, Periapical Radiographic Image | $28 | 0% | $28 |
| X-Ray - Two Images, Bitewings | $46 | 0% | $46 |
| X-Ray - Whole Mouth from Outside Mouth | $165 | 0% | $165 |
