| Dental Cleaning - Adult | $90 | 0% | $90 |
| Dental Cleaning - Child | $86 | 0% | $86 |
| Dental Exam - Comprehensive | $84 | 0% | $84 |
| Dental Exam - Periodic, Established Patient | $42 | 0% | $42 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $155 | 0% | $155 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $246 | 0% | $246 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $197 | 0% | $197 |
| Dental Filling - White (Resin): One Surface, Anterior | $167 | 0% | $167 |
| Dental Filling - White (Resin): One Surface, Posterior | $155 | 0% | $155 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $246 | 0% | $246 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $171 | 0% | $171 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $217 | 0% | $217 |
| Flouride - Topical Varnish Application | $43 | 0% | $43 |
| Fluoride - Topical Application | $34 | 0% | $34 |
| Maintenance Therapy - Periodontal | $140 | 0% | $140 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $231 | 0% | $231 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $76 | 0% | $76 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $200 | 0% | $200 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
| X-Ray - Complete Intraoral Series | $132 | 0% | $132 |
| X-Ray - Four Images, Bitewings | $61 | 0% | $61 |
| X-Ray - Intraoral, Periapical Radiographic Image | $28 | 0% | $28 |
| X-Ray - Two Images, Bitewings | $46 | 0% | $46 |
| X-Ray - Whole Mouth from Outside Mouth | $118 | 0% | $118 |
