| Dental Cleaning - Adult | $122 | 0% | $122 |
| Dental Cleaning - Child | $98 | 0% | $98 |
| Dental Exam - Comprehensive | $106 | 0% | $106 |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $221 | 0% | $221 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $401 | 0% | $401 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $308 | 0% | $308 |
| Dental Filling - White (Resin): One Surface, Anterior | $200 | 0% | $200 |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | 0% | $221 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $401 | 0% | $401 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $242 | 0% | $242 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $308 | 0% | $308 |
| Flouride - Topical Varnish Application | $53 | 0% | $53 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | 0% | $103 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | 0% | $68 |
| Tooth Extraction - Elevation and/or Forceps Removal | $221 | 0% | $221 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Complete Intraoral Series | $203 | 0% | $203 |
| X-Ray - Four Images, Bitewings | $83 | 0% | $83 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
| X-Ray - Two Images, Bitewings | $59 | 0% | $59 |
| X-Ray - Whole Mouth from Outside Mouth | $151 | 0% | $151 |
