| Dental Cleaning - Adult | $126 | 0% | $126 |
| Dental Cleaning - Child | $90 | 0% | $90 |
| Dental Exam - Comprehensive | $121 | 0% | $121 |
| Dental Exam - Periodic, Established Patient | $71 | 0% | $71 |
| Dental Filling - White (Resin): One Surface, Anterior | $188 | 0% | $188 |
| Dental Filling - White (Resin): One Surface, Posterior | $200 | 0% | $200 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $282 | 0% | $282 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $221 | 0% | $221 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $235 | 0% | $235 |
| Flouride - Topical Varnish Application | $68 | 0% | $68 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $104 | 0% | $104 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $72 | 0% | $72 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $41 | 0% | $41 |
| X-Ray - Complete Intraoral Series | $194 | 0% | $194 |
| X-Ray - Four Images, Bitewings | $95 | 0% | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $60 | 0% | $60 |
| X-Ray - Two Images, Bitewings | $68 | 0% | $68 |
