| Dental Cleaning - Adult | $107 | 0% | $107 |
| Dental Cleaning - Child | $88 | 0% | $88 |
| Dental Exam - Comprehensive | $84 | 0% | $84 |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $176 | 0% | $176 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $204 | 0% | $204 |
| Dental Filling - White (Resin): One Surface, Anterior | $332 | 0% | $332 |
| Dental Filling - White (Resin): One Surface, Posterior | $180 | 0% | $180 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $218 | 0% | $218 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $231 | 0% | $231 |
| Fluoride - Topical Application | $32 | 0% | $32 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | 0% | $88 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | 0% | $71 |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | 0% | $184 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
| X-Ray - Complete Intraoral Series | $239 | 0% | $239 |
| X-Ray - Four Images, Bitewings | $86 | 0% | $86 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
| X-Ray - Two Images, Bitewings | $69 | 0% | $69 |
| X-Ray - Whole Mouth from Outside Mouth | $179 | 0% | $179 |
