| Dental Cleaning - Adult | $218 | 0% | $218 |
| Dental Exam - Periodic, Established Patient | $92 | 0% | $92 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $166 | 0% | $166 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $289 | 0% | $289 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $240 | 0% | $240 |
| Dental Filling - White (Resin): One Surface, Anterior | $309 | 0% | $309 |
| Dental Filling - White (Resin): One Surface, Posterior | $332 | 0% | $332 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $578 | 0% | $578 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $384 | 0% | $384 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $481 | 0% | $481 |
| Flouride - Topical Varnish Application | $46 | 0% | $46 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $176 | 0% | $176 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $21 | 0% | $21 |
| X-Ray - Four Images, Bitewings | $153 | 0% | $153 |
| X-Ray - Intraoral, Periapical Radiographic Image | $57 | 0% | $57 |
| X-Ray - Whole Mouth from Outside Mouth | $277 | 0% | $277 |
