| Dental Cleaning - Adult | $105 | 0% | $105 |
| Dental Cleaning - Child | $85 | 0% | $85 |
| Dental Exam - Comprehensive | $90 | 0% | $90 |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | 0% | $189 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $222 | 0% | $222 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $259 | 0% | $259 |
| Dental Filling - White (Resin): One Surface, Anterior | $165 | 0% | $165 |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | 0% | $189 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | 0% | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $208 | 0% | $208 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $259 | 0% | $259 |
| Fluoride - Topical Application | $43 | 0% | $43 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | 0% | $88 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | 0% | $184 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
| X-Ray - Complete Intraoral Series | $146 | 0% | $146 |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
| X-Ray - Whole Mouth from Outside Mouth | $129 | 0% | $129 |
