| Dental Cleaning - Adult | $90 | 0% | $90 |
| Dental Cleaning - Child | $124 | 0% | $124 |
| Dental Exam - Periodic, Established Patient | $41 | 0% | $41 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $182 | 0% | $182 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $269 | 0% | $269 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $231 | 0% | $231 |
| Dental Filling - White (Resin): One Surface, Anterior | $165 | 0% | $165 |
| Dental Filling - White (Resin): One Surface, Posterior | $182 | 0% | $182 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $269 | 0% | $269 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $197 | 0% | $197 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $231 | 0% | $231 |
| Fluoride - Topical Application | $38 | 0% | $38 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $82 | 0% | $82 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $20 | 0% | $20 |
| X-Ray - Complete Intraoral Series | $144 | 0% | $144 |
| X-Ray - Intraoral, Periapical Radiographic Image | $29 | 0% | $29 |
| X-Ray - Two Images, Bitewings | $41 | 0% | $41 |
