| Dental Cleaning - Adult | $155 | 0% | $155 |
| Dental Cleaning - Child | $118 | 0% | $118 |
| Dental Exam - Comprehensive | $121 | 0% | $121 |
| Dental Exam - Periodic, Established Patient | $70 | 0% | $70 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $185 | 0% | $185 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $339 | 0% | $339 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $268 | 0% | $268 |
| Dental Filling - White (Resin): One Surface, Anterior | $208 | 0% | $208 |
| Dental Filling - White (Resin): One Surface, Posterior | $200 | 0% | $200 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $240 | 0% | $240 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $285 | 0% | $285 |
| Fluoride - Topical Application | $71 | 0% | $71 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $310 | 0% | $310 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $148 | 0% | $148 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | 0% | $38 |
| X-Ray - Complete Intraoral Series | $174 | 0% | $174 |
| X-Ray - Four Images, Bitewings | $90 | 0% | $90 |
| X-Ray - Intraoral, Periapical Radiographic Image | $47 | 0% | $47 |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
