| Dental Cleaning - Adult | $116 | 0% | $116 |
| Dental Cleaning - Child | $82 | 0% | $82 |
| Dental Exam - Comprehensive | $90 | 0% | $90 |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $236 | 0% | $236 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $370 | 0% | $370 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $294 | 0% | $294 |
| Dental Filling - White (Resin): One Surface, Anterior | $236 | 0% | $236 |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | 0% | $221 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $368 | 0% | $368 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $239 | 0% | $239 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $289 | 0% | $289 |
| Flouride - Topical Varnish Application | $47 | 0% | $47 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | 0% | $88 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $45 | 0% | $45 |
| X-Ray - Complete Intraoral Series | $158 | 0% | $158 |
| X-Ray - Four Images, Bitewings | $74 | 0% | $74 |
| X-Ray - Intraoral, Periapical Radiographic Image | $71 | 0% | $71 |
| X-Ray - Whole Mouth from Outside Mouth | $147 | 0% | $147 |
