| Dental Cleaning - Adult | $87 | 0% | $87 |
| Dental Cleaning - Child | $84 | 0% | $84 |
| Dental Exam - Comprehensive | $91 | 0% | $91 |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | 0% | $189 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $205 | 0% | $205 |
| Dental Filling - White (Resin): One Surface, Anterior | $157 | 0% | $157 |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | 0% | $189 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $318 | 0% | $318 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $205 | 0% | $205 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $236 | 0% | $236 |
| Flouride - Topical Varnish Application | $42 | 0% | $42 |
| Maintenance Therapy - Periodontal | $147 | 0% | $147 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $84 | 0% | $84 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $55 | 0% | $55 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
| X-Ray - Complete Intraoral Series | $126 | 0% | $126 |
| X-Ray - Four Images, Bitewings | $60 | 0% | $60 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $60 | 0% | $60 |
| X-Ray - Whole Mouth from Outside Mouth | $158 | 0% | $158 |
