| Dental Cleaning - Adult | $133 | 0% | $133 |
| Dental Cleaning - Child | $91 | 0% | $91 |
| Dental Exam - Comprehensive | $108 | 0% | $108 |
| Dental Exam - Periodic, Established Patient | $61 | 0% | $61 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $215 | 0% | $215 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $289 | 0% | $289 |
| Dental Filling - White (Resin): One Surface, Posterior | $215 | 0% | $215 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $357 | 0% | $357 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $289 | 0% | $289 |
| Flouride - Topical Varnish Application | $74 | 0% | $74 |
| Fluoride - Topical Application | $53 | 0% | $53 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $159 | 0% | $159 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Complete Intraoral Series | $210 | 0% | $210 |
| X-Ray - Four Images, Bitewings | $100 | 0% | $100 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
| X-Ray - Two Images, Bitewings | $77 | 0% | $77 |
