| Dental Cleaning - Adult | $86 | 0% | $86 |
| Dental Cleaning - Child | $70 | 0% | $70 |
| Dental Exam - Comprehensive | $74 | 0% | $74 |
| Dental Exam - Periodic, Established Patient | $41 | 0% | $41 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $131 | 0% | $131 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $194 | 0% | $194 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $168 | 0% | $168 |
| Dental Filling - White (Resin): One Surface, Anterior | $147 | 0% | $147 |
| Dental Filling - White (Resin): One Surface, Posterior | $158 | 0% | $158 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $254 | 0% | $254 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $189 | 0% | $189 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $200 | 0% | $200 |
| Flouride - Topical Varnish Application | $40 | 0% | $40 |
| Fluoride - Topical Application | $35 | 0% | $35 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $74 | 0% | $74 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $53 | 0% | $53 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
| X-Ray - Intraoral, Periapical Radiographic Image | $29 | 0% | $29 |
| X-Ray - Two Images, Bitewings | $40 | 0% | $40 |
| X-Ray - Whole Mouth from Outside Mouth | $116 | 0% | $116 |
