| Dental Cleaning - Adult | $101 | 0% | $101 |
| Dental Cleaning - Child | $76 | 0% | $76 |
| Dental Exam - Comprehensive | $77 | 0% | $77 |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $158 | 0% | $158 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $272 | 0% | $272 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $207 | 0% | $207 |
| Dental Filling - White (Resin): One Surface, Anterior | $144 | 0% | $144 |
| Dental Filling - White (Resin): One Surface, Posterior | $158 | 0% | $158 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $272 | 0% | $272 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $177 | 0% | $177 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $207 | 0% | $207 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $70 | 0% | $70 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $56 | 0% | $56 |
| Tooth Extraction - Elevation and/or Forceps Removal | $164 | 0% | $164 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $23 | 0% | $23 |
| X-Ray - Complete Intraoral Series | $142 | 0% | $142 |
| X-Ray - Four Images, Bitewings | $65 | 0% | $65 |
| X-Ray - Intraoral, Periapical Radiographic Image | $29 | 0% | $29 |
| X-Ray - Two Images, Bitewings | $44 | 0% | $44 |
| X-Ray - Whole Mouth from Outside Mouth | $116 | 0% | $116 |
