| Dental Cleaning - Adult | $131 | 0% | $131 |
| Dental Cleaning - Child | $103 | 0% | $103 |
| Dental Exam - Periodic, Established Patient | $68 | 0% | $68 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $257 | 0% | $257 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $310 | 0% | $310 |
| Dental Filling - White (Resin): One Surface, Anterior | $236 | 0% | $236 |
| Dental Filling - White (Resin): One Surface, Posterior | $252 | 0% | $252 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $423 | 0% | $423 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $310 | 0% | $310 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $310 | 0% | $310 |
| Flouride - Topical Varnish Application | $51 | 0% | $51 |
| Maintenance Therapy - Periodontal | $177 | 0% | $177 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $126 | 0% | $126 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $47 | 0% | $47 |
| X-Ray - Complete Intraoral Series | $198 | 0% | $198 |
| X-Ray - Four Images, Bitewings | $100 | 0% | $100 |
| X-Ray - Intraoral, Periapical Radiographic Image | $50 | 0% | $50 |
| X-Ray - Two Images, Bitewings | $42 | 0% | $42 |
