| Dental Cleaning - Adult | $86 | 0% | $86 |
| Dental Exam - Comprehensive | $77 | 0% | $77 |
| Dental Exam - Periodic, Established Patient | $42 | 0% | $42 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $173 | 0% | $173 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $281 | 0% | $281 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $216 | 0% | $216 |
| Dental Filling - White (Resin): One Surface, Posterior | $154 | 0% | $154 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $281 | 0% | $281 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $170 | 0% | $170 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $321 | 0% | $321 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $74 | 0% | $74 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $45 | 0% | $45 |
| Tooth Extraction - Elevation and/or Forceps Removal | $260 | 0% | $260 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $17 | 0% | $17 |
| X-Ray - Four Images, Bitewings | $60 | 0% | $60 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
