| Dental Cleaning - Adult | $109 | 0% | $109 |
| Dental Cleaning - Child | $90 | 0% | $90 |
| Dental Exam - Comprehensive | $111 | 0% | $111 |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $153 | 0% | $153 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $230 | 0% | $230 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $192 | 0% | $192 |
| Dental Filling - White (Resin): One Surface, Anterior | $188 | 0% | $188 |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | 0% | $189 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | 0% | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $227 | 0% | $227 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
| Flouride - Topical Varnish Application | $48 | 0% | $48 |
| Maintenance Therapy - Periodontal | $231 | 0% | $231 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $106 | 0% | $106 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | 0% | $71 |
| Tooth Extraction - Elevation and/or Forceps Removal | $418 | 0% | $418 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $41 | 0% | $41 |
| X-Ray - Complete Intraoral Series | $148 | 0% | $148 |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | 0% | $46 |
| X-Ray - Two Images, Bitewings | $57 | 0% | $57 |
