| Dental Cleaning - Adult | $128 | 0% | $128 |
| Dental Cleaning - Child | $95 | 0% | $95 |
| Dental Exam - Comprehensive | $105 | 0% | $105 |
| Dental Exam - Periodic, Established Patient | $61 | 0% | $61 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $176 | 0% | $176 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $231 | 0% | $231 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $278 | 0% | $278 |
| Dental Filling - White (Resin): One Surface, Anterior | $179 | 0% | $179 |
| Dental Filling - White (Resin): One Surface, Posterior | $200 | 0% | $200 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $536 | 0% | $536 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $221 | 0% | $221 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $278 | 0% | $278 |
| Flouride - Topical Varnish Application | $47 | 0% | $47 |
| Fluoride - Topical Application | $47 | 0% | $47 |
| Maintenance Therapy - Periodontal | $158 | 0% | $158 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | 0% | $103 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $42 | 0% | $42 |
| X-Ray - Complete Intraoral Series | $163 | 0% | $163 |
| X-Ray - Four Images, Bitewings | $86 | 0% | $86 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
| X-Ray - Two Images, Bitewings | $65 | 0% | $65 |
