| Dental Cleaning - Adult | $168 | 0% | $168 |
| Dental Cleaning - Child | $63 | 0% | $63 |
| Dental Exam - Comprehensive | $82 | 0% | $82 |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $152 | 0% | $152 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $214 | 0% | $214 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $192 | 0% | $192 |
| Dental Filling - White (Resin): One Surface, Anterior | $144 | 0% | $144 |
| Dental Filling - White (Resin): One Surface, Posterior | $152 | 0% | $152 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $433 | 0% | $433 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $189 | 0% | $189 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $389 | 0% | $389 |
| Flouride - Topical Varnish Application | $44 | 0% | $44 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $68 | 0% | $68 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $277 | 0% | $277 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $46 | 0% | $46 |
| X-Ray - Whole Mouth from Outside Mouth | $109 | 0% | $109 |
