| Dental Cleaning - Adult | $100 | 0% | $100 |
| Dental Cleaning - Child | $86 | 0% | $86 |
| Dental Exam - Comprehensive | $103 | 0% | $103 |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $184 | 0% | $184 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $310 | 0% | $310 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $231 | 0% | $231 |
| 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 | $310 | 0% | $310 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $205 | 0% | $205 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $231 | 0% | $231 |
| Flouride - Topical Varnish Application | $40 | 0% | $40 |
| Fluoride - Topical Application | $37 | 0% | $37 |
| Maintenance Therapy - Periodontal | $147 | 0% | $147 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | 0% | $95 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $56 | 0% | $56 |
| Tooth Extraction - Elevation and/or Forceps Removal | $194 | 0% | $194 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
| X-Ray - Complete Intraoral Series | $156 | 0% | $156 |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
