| Dental Cleaning - Adult | $155 | 0% | $155 |
| Dental Cleaning - Child | $120 | 0% | $120 |
| Dental Exam - Comprehensive | $120 | 0% | $120 |
| Dental Exam - Periodic, Established Patient | $74 | 0% | $74 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | 0% | $208 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $361 | 0% | $361 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $303 | 0% | $303 |
| Dental Filling - White (Resin): One Surface, Anterior | $196 | 0% | $196 |
| Dental Filling - White (Resin): One Surface, Posterior | $232 | 0% | $232 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $460 | 0% | $460 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $299 | 0% | $299 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $321 | 0% | $321 |
| Flouride - Topical Varnish Application | $56 | 0% | $56 |
| Fluoride - Topical Application | $69 | 0% | $69 |
| Maintenance Therapy - Periodontal | $193 | 0% | $193 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $320 | 0% | $320 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $108 | 0% | $108 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $89 | 0% | $89 |
| Tooth Extraction - Elevation and/or Forceps Removal | $273 | 0% | $273 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
| X-Ray - Complete Intraoral Series | $218 | 0% | $218 |
| X-Ray - Four Images, Bitewings | $120 | 0% | $120 |
| X-Ray - Intraoral, Periapical Radiographic Image | $53 | 0% | $53 |
| X-Ray - Two Images, Bitewings | $76 | 0% | $76 |
| X-Ray - Whole Mouth from Outside Mouth | $164 | 0% | $164 |
