| Dental Cleaning - Adult | $92 | 0% | $92 |
| Dental Cleaning - Child | $74 | 0% | $74 |
| Dental Exam - Comprehensive | $85 | 0% | $85 |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $227 | 0% | $227 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $205 | 0% | $205 |
| Dental Filling - White (Resin): One Surface, Anterior | $147 | 0% | $147 |
| Dental Filling - White (Resin): One Surface, Posterior | $173 | 0% | $173 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $257 | 0% | $257 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $179 | 0% | $179 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $205 | 0% | $205 |
| Fluoride - Topical Application | $46 | 0% | $46 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $236 | 0% | $236 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $79 | 0% | $79 |
| Tooth Extraction - Elevation and/or Forceps Removal | $168 | 0% | $168 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
| X-Ray - Complete Intraoral Series | $144 | 0% | $144 |
| X-Ray - Four Images, Bitewings | $66 | 0% | $66 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $61 | 0% | $61 |
