| Dental Cleaning - Adult | $131 | 0% | $131 |
| Dental Cleaning - Child | $118 | 0% | $118 |
| Dental Exam - Comprehensive | $96 | 0% | $96 |
| Dental Exam - Periodic, Established Patient | $69 | 0% | $69 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $185 | 0% | $185 |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | 0% | $221 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $374 | 0% | $374 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $240 | 0% | $240 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $249 | 0% | $249 |
| Fluoride - Topical Application | $71 | 0% | $71 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $82 | 0% | $82 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | 0% | $59 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
| X-Ray - Complete Intraoral Series | $190 | 0% | $190 |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $30 | 0% | $30 |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
