| Dental Cleaning - Adult | $110 | 0% | $110 |
| Dental Cleaning - Child | $89 | 0% | $89 |
| Dental Exam - Comprehensive | $95 | 0% | $95 |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $209 | 0% | $209 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $249 | 0% | $249 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $231 | 0% | $231 |
| Dental Filling - White (Resin): One Surface, Anterior | $188 | 0% | $188 |
| Dental Filling - White (Resin): One Surface, Posterior | $212 | 0% | $212 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $350 | 0% | $350 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $231 | 0% | $231 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $275 | 0% | $275 |
| Flouride - Topical Varnish Application | $45 | 0% | $45 |
| Maintenance Therapy - Periodontal | $155 | 0% | $155 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $542 | 0% | $542 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $91 | 0% | $91 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | 0% | $61 |
| Tooth Extraction - Elevation and/or Forceps Removal | $236 | 0% | $236 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | 0% | $30 |
| X-Ray - Complete Intraoral Series | $151 | 0% | $151 |
| X-Ray - Four Images, Bitewings | $76 | 0% | $76 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
| X-Ray - Two Images, Bitewings | $55 | 0% | $55 |
| X-Ray - Whole Mouth from Outside Mouth | $133 | 0% | $133 |
