| Dental Cleaning - Adult | $109 | 0% | $109 |
| Dental Cleaning - Child | $81 | 0% | $81 |
| Dental Exam - Comprehensive | $92 | 0% | $92 |
| Dental Exam - Periodic, Established Patient | $54 | 0% | $54 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $215 | 0% | $215 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $517 | 0% | $517 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $206 | 0% | $206 |
| Dental Filling - White (Resin): One Surface, Anterior | $206 | 0% | $206 |
| Dental Filling - White (Resin): One Surface, Posterior | $215 | 0% | $215 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $354 | 0% | $354 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $264 | 0% | $264 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $274 | 0% | $274 |
| Flouride - Topical Varnish Application | $45 | 0% | $45 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $85 | 0% | $85 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | 0% | $61 |
| Tooth Extraction - Elevation and/or Forceps Removal | $252 | 0% | $252 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $22 | 0% | $22 |
| X-Ray - Complete Intraoral Series | $144 | 0% | $144 |
| X-Ray - Four Images, Bitewings | $76 | 0% | $76 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | 0% | $36 |
| X-Ray - Two Images, Bitewings | $55 | 0% | $55 |
| X-Ray - Whole Mouth from Outside Mouth | $143 | 0% | $143 |
