| Dental Cleaning - Adult | $126 | 0% | $126 |
| Dental Cleaning - Child | $179 | 0% | $179 |
| Dental Exam - Comprehensive | $82 | 0% | $82 |
| Dental Exam - Periodic, Established Patient | $46 | 0% | $46 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $296 | 0% | $296 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $306 | 0% | $306 |
| Dental Filling - White (Resin): One Surface, Anterior | $323 | 0% | $323 |
| Dental Filling - White (Resin): One Surface, Posterior | $176 | 0% | $176 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $624 | 0% | $624 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $207 | 0% | $207 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $242 | 0% | $242 |
| Flouride - Topical Varnish Application | $92 | 0% | $92 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $131 | 0% | $131 |
| Tooth Extraction - Elevation and/or Forceps Removal | $242 | 0% | $242 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $22 | 0% | $22 |
| X-Ray - Complete Intraoral Series | $176 | 0% | $176 |
| X-Ray - Four Images, Bitewings | $78 | 0% | $78 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
| X-Ray - Two Images, Bitewings | $62 | 0% | $62 |
| X-Ray - Whole Mouth from Outside Mouth | $140 | 0% | $140 |
