| Dental Cleaning - Adult | $99 | 0% | $99 |
| Dental Cleaning - Child | $79 | 0% | $79 |
| Dental Exam - Comprehensive | $111 | 0% | $111 |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $171 | 0% | $171 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $236 | 0% | $236 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $201 | 0% | $201 |
| Dental Filling - White (Resin): One Surface, Anterior | $163 | 0% | $163 |
| Dental Filling - White (Resin): One Surface, Posterior | $174 | 0% | $174 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $277 | 0% | $277 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $230 | 0% | $230 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $227 | 0% | $227 |
| Flouride - Topical Varnish Application | $46 | 0% | $46 |
| Fluoride - Topical Application | $40 | 0% | $40 |
| Maintenance Therapy - Periodontal | $143 | 0% | $143 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $81 | 0% | $81 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $62 | 0% | $62 |
| Tooth Extraction - Elevation and/or Forceps Removal | $205 | 0% | $205 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
| X-Ray - Complete Intraoral Series | $144 | 0% | $144 |
| X-Ray - Four Images, Bitewings | $90 | 0% | $90 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
| X-Ray - Two Images, Bitewings | $58 | 0% | $58 |
| X-Ray - Whole Mouth from Outside Mouth | $121 | 0% | $121 |
