| Dental Cleaning - Adult | $130 | 0% | $130 |
| Dental Cleaning - Child | $104 | 0% | $104 |
| Dental Exam - Comprehensive | $137 | 0% | $137 |
| Dental Exam - Periodic, Established Patient | $76 | 0% | $76 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $271 | 0% | $271 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $404 | 0% | $404 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $331 | 0% | $331 |
| Dental Filling - White (Resin): One Surface, Anterior | $245 | 0% | $245 |
| Dental Filling - White (Resin): One Surface, Posterior | $275 | 0% | $275 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $416 | 0% | $416 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $295 | 0% | $295 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $331 | 0% | $331 |
| Flouride - Topical Varnish Application | $66 | 0% | $66 |
| Maintenance Therapy - Periodontal | $210 | 0% | $210 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $383 | 0% | $383 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | 0% | $105 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $82 | 0% | $82 |
| Tooth Extraction - Elevation and/or Forceps Removal | $275 | 0% | $275 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $39 | 0% | $39 |
| X-Ray - Complete Intraoral Series | $192 | 0% | $192 |
| X-Ray - Four Images, Bitewings | $97 | 0% | $97 |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | 0% | $46 |
| X-Ray - Two Images, Bitewings | $65 | 0% | $65 |
| X-Ray - Whole Mouth from Outside Mouth | $167 | 0% | $167 |
