| Dental Cleaning - Adult | $105 | 0% | $105 |
| Dental Cleaning - Child | $74 | 0% | $74 |
| Dental Exam - Comprehensive | $89 | 0% | $89 |
| Dental Exam - Periodic, Established Patient | $50 | 0% | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $184 | 0% | $184 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $263 | 0% | $263 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | 0% | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $163 | 0% | $163 |
| Dental Filling - White (Resin): One Surface, Posterior | $184 | 0% | $184 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $320 | 0% | $320 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $208 | 0% | $208 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
| Flouride - Topical Varnish Application | $42 | 0% | $42 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $86 | 0% | $86 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $55 | 0% | $55 |
| Tooth Extraction - Elevation and/or Forceps Removal | $181 | 0% | $181 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
| X-Ray - Complete Intraoral Series | $203 | 0% | $203 |
| X-Ray - Four Images, Bitewings | $76 | 0% | $76 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $62 | 0% | $62 |
| X-Ray - Whole Mouth from Outside Mouth | $127 | 0% | $127 |
