| Dental Cleaning - Adult | $116 | 0% | $116 |
| Dental Cleaning - Child | $88 | 0% | $88 |
| Dental Exam - Comprehensive | $108 | 0% | $108 |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $209 | 0% | $209 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $394 | 0% | $394 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | 0% | $263 |
| Dental Filling - White (Resin): One Surface, Posterior | $239 | 0% | $239 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $268 | 0% | $268 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $305 | 0% | $305 |
| Flouride - Topical Varnish Application | $57 | 0% | $57 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $97 | 0% | $97 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
| X-Ray - Complete Intraoral Series | $169 | 0% | $169 |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
| X-Ray - Two Images, Bitewings | $57 | 0% | $57 |
