| Dental Cleaning - Adult | $126 | 0% | $126 |
| Dental Cleaning - Child | $95 | 0% | $95 |
| Dental Exam - Comprehensive | $79 | 0% | $79 |
| Dental Exam - Periodic, Established Patient | $55 | 0% | $55 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $185 | 0% | $185 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $290 | 0% | $290 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $227 | 0% | $227 |
| Dental Filling - White (Resin): One Surface, Anterior | $179 | 0% | $179 |
| Dental Filling - White (Resin): One Surface, Posterior | $200 | 0% | $200 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $316 | 0% | $316 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $269 | 0% | $269 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $231 | 0% | $231 |
| Fluoride - Topical Application | $37 | 0% | $37 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | 0% | $101 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $191 | 0% | $191 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
| X-Ray - Complete Intraoral Series | $168 | 0% | $168 |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $21 | 0% | $21 |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
