| Dental Cleaning - Adult | $118 | 0% | $118 |
| Dental Cleaning - Child | $89 | 0% | $89 |
| Dental Exam - Comprehensive | $108 | 0% | $108 |
| Dental Exam - Periodic, Established Patient | $70 | 0% | $70 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $205 | 0% | $205 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $257 | 0% | $257 |
| Dental Filling - White (Resin): One Surface, Posterior | $205 | 0% | $205 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $257 | 0% | $257 |
| Flouride - Topical Varnish Application | $57 | 0% | $57 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | 0% | $100 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $72 | 0% | $72 |
| Tooth Extraction - Elevation and/or Forceps Removal | $206 | 0% | $206 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
| X-Ray - Complete Intraoral Series | $209 | 0% | $209 |
| X-Ray - Four Images, Bitewings | $88 | 0% | $88 |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | 0% | $46 |
| X-Ray - Two Images, Bitewings | $67 | 0% | $67 |
| X-Ray - Whole Mouth from Outside Mouth | $142 | 0% | $142 |
