| Dental Cleaning - Adult | $95 | 0% | $95 |
| Dental Cleaning - Child | $118 | 0% | $118 |
| Dental Exam - Comprehensive | $91 | 0% | $91 |
| Dental Exam - Periodic, Established Patient | $69 | 0% | $69 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $158 | 0% | $158 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $269 | 0% | $269 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $208 | 0% | $208 |
| Dental Filling - White (Resin): One Surface, Anterior | $208 | 0% | $208 |
| Dental Filling - White (Resin): One Surface, Posterior | $158 | 0% | $158 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $370 | 0% | $370 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $236 | 0% | $236 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $203 | 0% | $203 |
| Flouride - Topical Varnish Application | $74 | 0% | $74 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $84 | 0% | $84 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $67 | 0% | $67 |
| Tooth Extraction - Elevation and/or Forceps Removal | $191 | 0% | $191 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
| X-Ray - Complete Intraoral Series | $139 | 0% | $139 |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $26 | 0% | $26 |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
| X-Ray - Whole Mouth from Outside Mouth | $121 | 0% | $121 |
