| Dental Cleaning - Adult | $100 | 0% | $100 |
| Dental Cleaning - Child | $79 | 0% | $79 |
| Dental Exam - Comprehensive | $90 | 0% | $90 |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | 0% | $189 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $313 | 0% | $313 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $261 | 0% | $261 |
| Dental Filling - White (Resin): One Surface, Anterior | $165 | 0% | $165 |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | 0% | $189 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $313 | 0% | $313 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $202 | 0% | $202 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $261 | 0% | $261 |
| Flouride - Topical Varnish Application | $32 | 0% | $32 |
| Fluoride - Topical Application | $32 | 0% | $32 |
| Maintenance Therapy - Periodontal | $132 | 0% | $132 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $82 | 0% | $82 |
| Root Canal - Anterior Tooth | $870 | 0% | $870 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $51 | 0% | $51 |
| Tooth Extraction - Elevation and/or Forceps Removal | $174 | 0% | $174 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
| X-Ray - Complete Intraoral Series | $137 | 0% | $137 |
| X-Ray - Four Images, Bitewings | $63 | 0% | $63 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
