| Dental Cleaning - Adult | $121 | 0% | $121 |
| Dental Cleaning - Child | $89 | 0% | $89 |
| Dental Exam - Comprehensive | $101 | 0% | $101 |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $194 | 0% | $194 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $294 | 0% | $294 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $231 | 0% | $231 |
| Dental Filling - White (Resin): One Surface, Posterior | $209 | 0% | $209 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $194 | 0% | $194 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $247 | 0% | $247 |
| Flouride - Topical Varnish Application | $37 | 0% | $37 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $63 | 0% | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $195 | 0% | $195 |
| X-Ray - Complete Intraoral Series | $173 | 0% | $173 |
| X-Ray - Four Images, Bitewings | $63 | 0% | $63 |
| X-Ray - Intraoral, Periapical Radiographic Image | $47 | 0% | $47 |
| X-Ray - Two Images, Bitewings | $47 | 0% | $47 |
