| Dental Cleaning - Adult | $111 | 0% | $111 |
| Dental Cleaning - Child | $120 | 0% | $120 |
| Dental Exam - Comprehensive | $120 | 0% | $120 |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $203 | 0% | $203 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $310 | 0% | $310 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $260 | 0% | $260 |
| Dental Filling - White (Resin): One Surface, Posterior | $184 | 0% | $184 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $205 | 0% | $205 |
| Flouride - Topical Varnish Application | $86 | 0% | $86 |
| Fluoride - Topical Application | $53 | 0% | $53 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $395 | 0% | $395 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $86 | 0% | $86 |
| Tooth Extraction - Elevation and/or Forceps Removal | $214 | 0% | $214 |
| X-Ray - Complete Intraoral Series | $144 | 0% | $144 |
| X-Ray - Four Images, Bitewings | $79 | 0% | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
| X-Ray - Two Images, Bitewings | $64 | 0% | $64 |
