| Dental Cleaning - Adult | $144 | 0% | $144 |
| Dental Cleaning - Child | $120 | 0% | $120 |
| Dental Exam - Comprehensive | $120 | 0% | $120 |
| Dental Exam - Periodic, Established Patient | $66 | 0% | $66 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | 0% | $208 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $436 | 0% | $436 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | 0% | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $212 | 0% | $212 |
| Dental Filling - White (Resin): One Surface, Posterior | $231 | 0% | $231 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $400 | 0% | $400 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $247 | 0% | $247 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $320 | 0% | $320 |
| Flouride - Topical Varnish Application | $63 | 0% | $63 |
| Fluoride - Topical Application | $69 | 0% | $69 |
| Maintenance Therapy - Periodontal | $185 | 0% | $185 |
| 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 | $110 | 0% | $110 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $80 | 0% | $80 |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | 0% | $184 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | 0% | $38 |
| X-Ray - Complete Intraoral Series | $193 | 0% | $193 |
| X-Ray - Four Images, Bitewings | $93 | 0% | $93 |
| X-Ray - Intraoral, Periapical Radiographic Image | $44 | 0% | $44 |
| X-Ray - Two Images, Bitewings | $68 | 0% | $68 |
| X-Ray - Whole Mouth from Outside Mouth | $163 | 0% | $163 |
