| Dental Cleaning - Adult | $129 | 0% | $129 |
| Dental Cleaning - Child | $100 | 0% | $100 |
| Dental Exam - Comprehensive | $130 | 0% | $130 |
| Dental Exam - Periodic, Established Patient | $81 | 0% | $81 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $297 | 0% | $297 |
| Dental Filling - White (Resin): One Surface, Posterior | $257 | 0% | $257 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $412 | 0% | $412 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $334 | 0% | $334 |
| Flouride - Topical Varnish Application | $61 | 0% | $61 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $144 | 0% | $144 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $87 | 0% | $87 |
| Tooth Extraction - Elevation and/or Forceps Removal | $271 | 0% | $271 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
| X-Ray - Complete Intraoral Series | $260 | 0% | $260 |
| X-Ray - Four Images, Bitewings | $92 | 0% | $92 |
| X-Ray - Intraoral, Periapical Radiographic Image | $45 | 0% | $45 |
| X-Ray - Two Images, Bitewings | $66 | 0% | $66 |
| X-Ray - Whole Mouth from Outside Mouth | $194 | 0% | $194 |
