| Dental Cleaning - Adult | $122 | 0% | $122 |
| Dental Cleaning - Child | $151 | 0% | $151 |
| Dental Exam - Periodic, Established Patient | $54 | 0% | $54 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $193 | 0% | $193 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $362 | 0% | $362 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $230 | 0% | $230 |
| Dental Filling - White (Resin): One Surface, Anterior | $267 | 0% | $267 |
| Dental Filling - White (Resin): One Surface, Posterior | $193 | 0% | $193 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $706 | 0% | $706 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $327 | 0% | $327 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $575 | 0% | $575 |
| Fluoride - Topical Application | $44 | 0% | $44 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $117 | 0% | $117 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $72 | 0% | $72 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $50 | 0% | $50 |
| X-Ray - Complete Intraoral Series | $187 | 0% | $187 |
| X-Ray - Four Images, Bitewings | $72 | 0% | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
| X-Ray - Two Images, Bitewings | $101 | 0% | $101 |
| X-Ray - Whole Mouth from Outside Mouth | $170 | 0% | $170 |
