| Dental Cleaning - Adult | $111 | 0% | $111 |
| Dental Cleaning - Child | $95 | 0% | $95 |
| Dental Exam - Comprehensive | $158 | 0% | $158 |
| Dental Exam - Periodic, Established Patient | $56 | 0% | $56 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $179 | 0% | $179 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $247 | 0% | $247 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $210 | 0% | $210 |
| Dental Filling - White (Resin): One Surface, Anterior | $357 | 0% | $357 |
| Dental Filling - White (Resin): One Surface, Posterior | $412 | 0% | $412 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $242 | 0% | $242 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $189 | 0% | $189 |
| Flouride - Topical Varnish Application | $58 | 0% | $58 |
| Fluoride - Topical Application | $53 | 0% | $53 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | 0% | $95 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
| X-Ray - Complete Intraoral Series | $158 | 0% | $158 |
| X-Ray - Four Images, Bitewings | $95 | 0% | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $45 | 0% | $45 |
| X-Ray - Two Images, Bitewings | $79 | 0% | $79 |
