| Dental Cleaning - Adult | $95 | 0% | $95 |
| Dental Cleaning - Child | $68 | 0% | $68 |
| Dental Exam - Comprehensive | $74 | 0% | $74 |
| Dental Exam - Periodic, Established Patient | $42 | 0% | $42 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $206 | 0% | $206 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $231 | 0% | $231 |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | 0% | $184 |
| Dental Filling - White (Resin): One Surface, Posterior | $200 | 0% | $200 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $252 | 0% | $252 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $189 | 0% | $189 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $231 | 0% | $231 |
| Flouride - Topical Varnish Application | $38 | 0% | $38 |
| Fluoride - Topical Application | $38 | 0% | $38 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $67 | 0% | $67 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | 0% | $68 |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | 0% | $184 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
| X-Ray - Four Images, Bitewings | $66 | 0% | $66 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
| X-Ray - Two Images, Bitewings | $53 | 0% | $53 |
