| Dental Cleaning - Adult | $112 | 0% | $112 |
| Dental Cleaning - Child | $85 | 0% | $85 |
| Dental Exam - Comprehensive | $104 | 0% | $104 |
| Dental Exam - Periodic, Established Patient | $57 | 0% | $57 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $219 | 0% | $219 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $372 | 0% | $372 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $513 | 0% | $513 |
| Dental Filling - White (Resin): One Surface, Anterior | $203 | 0% | $203 |
| Dental Filling - White (Resin): One Surface, Posterior | $219 | 0% | $219 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $246 | 0% | $246 |
| Flouride - Topical Varnish Application | $48 | 0% | $48 |
| Maintenance Therapy - Periodontal | $162 | 0% | $162 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | 0% | $30 |
| X-Ray - Complete Intraoral Series | $160 | 0% | $160 |
| X-Ray - Four Images, Bitewings | $81 | 0% | $81 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
