| Dental Cleaning - Adult | $168 | 0% | $168 |
| Dental Cleaning - Child | $63 | 0% | $63 |
| Dental Exam - Comprehensive | $89 | 0% | $89 |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $210 | 0% | $210 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $336 | 0% | $336 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $273 | 0% | $273 |
| Dental Filling - White (Resin): One Surface, Anterior | $168 | 0% | $168 |
| Dental Filling - White (Resin): One Surface, Posterior | $210 | 0% | $210 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $336 | 0% | $336 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $231 | 0% | $231 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $273 | 0% | $273 |
| Flouride - Topical Varnish Application | $37 | 0% | $37 |
| Fluoride - Topical Application | $37 | 0% | $37 |
| Maintenance Therapy - Periodontal | $184 | 0% | $184 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $68 | 0% | $68 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $53 | 0% | $53 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $48 | 0% | $48 |
| X-Ray - Complete Intraoral Series | $131 | 0% | $131 |
| X-Ray - Four Images, Bitewings | $60 | 0% | $60 |
| X-Ray - Intraoral, Periapical Radiographic Image | $28 | 0% | $28 |
| X-Ray - Two Images, Bitewings | $39 | 0% | $39 |
