| Dental Cleaning - Adult | $95 | 0% | $95 |
| Dental Cleaning - Child | $64 | 0% | $64 |
| Dental Exam - Periodic, Established Patient | $40 | 0% | $40 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $165 | 0% | $165 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $228 | 0% | $228 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $189 | 0% | $189 |
| Dental Filling - White (Resin): One Surface, Anterior | $260 | 0% | $260 |
| Dental Filling - White (Resin): One Surface, Posterior | $281 | 0% | $281 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $464 | 0% | $464 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $376 | 0% | $376 |
| Flouride - Topical Varnish Application | $59 | 0% | $59 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $68 | 0% | $68 |
| X-Ray - Four Images, Bitewings | $64 | 0% | $64 |
| X-Ray - Intraoral, Periapical Radiographic Image | $26 | 0% | $26 |
| X-Ray - Two Images, Bitewings | $60 | 0% | $60 |
| X-Ray - Whole Mouth from Outside Mouth | $152 | 0% | $152 |
