| Dental Cleaning - Adult | $112 | 0% | $112 |
| Dental Cleaning - Child | $82 | 0% | $82 |
| Dental Exam - Comprehensive | $102 | 0% | $102 |
| Dental Exam - Periodic, Established Patient | $62 | 0% | $62 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $207 | 0% | $207 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $273 | 0% | $273 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $277 | 0% | $277 |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | 0% | $184 |
| Dental Filling - White (Resin): One Surface, Posterior | $207 | 0% | $207 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $357 | 0% | $357 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $441 | 0% | $441 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $277 | 0% | $277 |
| Flouride - Topical Varnish Application | $58 | 0% | $58 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $91 | 0% | $91 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | 0% | $68 |
| Tooth Extraction - Elevation and/or Forceps Removal | $215 | 0% | $215 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Complete Intraoral Series | $165 | 0% | $165 |
| X-Ray - Four Images, Bitewings | $75 | 0% | $75 |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
| X-Ray - Two Images, Bitewings | $60 | 0% | $60 |
| X-Ray - Whole Mouth from Outside Mouth | $165 | 0% | $165 |
