| Dental Cleaning - Adult | $140 | 0% | $140 |
| Dental Cleaning - Child | $106 | 0% | $106 |
| Dental Exam - Comprehensive | $163 | 0% | $163 |
| Dental Exam - Periodic, Established Patient | $83 | 0% | $83 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $197 | 0% | $197 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $373 | 0% | $373 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $294 | 0% | $294 |
| Dental Filling - White (Resin): One Surface, Anterior | $212 | 0% | $212 |
| Dental Filling - White (Resin): One Surface, Posterior | $233 | 0% | $233 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $419 | 0% | $419 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $296 | 0% | $296 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $335 | 0% | $335 |
| Flouride - Topical Varnish Application | $62 | 0% | $62 |
| Fluoride - Topical Application | $57 | 0% | $57 |
| Maintenance Therapy - Periodontal | $202 | 0% | $202 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $347 | 0% | $347 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $134 | 0% | $134 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $76 | 0% | $76 |
| Tooth Extraction - Elevation and/or Forceps Removal | $308 | 0% | $308 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $39 | 0% | $39 |
| X-Ray - Complete Intraoral Series | $212 | 0% | $212 |
| X-Ray - Four Images, Bitewings | $101 | 0% | $101 |
| X-Ray - Intraoral, Periapical Radiographic Image | $44 | 0% | $44 |
| X-Ray - Two Images, Bitewings | $67 | 0% | $67 |
| X-Ray - Whole Mouth from Outside Mouth | $202 | 0% | $202 |
