| Dental Cleaning - Adult | $158 | 0% | $158 |
| Dental Cleaning - Child | $76 | 0% | $76 |
| Dental Exam - Comprehensive | $141 | 0% | $141 |
| Dental Exam - Periodic, Established Patient | $69 | 0% | $69 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $163 | 0% | $163 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $271 | 0% | $271 |
| Dental Filling - White (Resin): One Surface, Anterior | $256 | 0% | $256 |
| Dental Filling - White (Resin): One Surface, Posterior | $286 | 0% | $286 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $443 | 0% | $443 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $229 | 0% | $229 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $368 | 0% | $368 |
| Flouride - Topical Varnish Application | $82 | 0% | $82 |
| Maintenance Therapy - Periodontal | $206 | 0% | $206 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $110 | 0% | $110 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $40 | 0% | $40 |
| X-Ray - Complete Intraoral Series | $235 | 0% | $235 |
| X-Ray - Four Images, Bitewings | $111 | 0% | $111 |
| X-Ray - Intraoral, Periapical Radiographic Image | $50 | 0% | $50 |
