| Dental Cleaning - Adult | $110 | 0% | $110 |
| Dental Cleaning - Child | $84 | 0% | $84 |
| Dental Exam - Comprehensive | $100 | 0% | $100 |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $210 | 0% | $210 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $368 | 0% | $368 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $268 | 0% | $268 |
| Dental Filling - White (Resin): One Surface, Anterior | $186 | 0% | $186 |
| Dental Filling - White (Resin): One Surface, Posterior | $210 | 0% | $210 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $368 | 0% | $368 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $221 | 0% | $221 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $268 | 0% | $268 |
| Flouride - Topical Varnish Application | $47 | 0% | $47 |
| Fluoride - Topical Application | $42 | 0% | $42 |
| Maintenance Therapy - Periodontal | $152 | 0% | $152 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $278 | 0% | $278 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | 0% | $95 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $210 | 0% | $210 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
| X-Ray - Complete Intraoral Series | $158 | 0% | $158 |
| X-Ray - Four Images, Bitewings | $74 | 0% | $74 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
| X-Ray - Two Images, Bitewings | $53 | 0% | $53 |
| X-Ray - Whole Mouth from Outside Mouth | $137 | 0% | $137 |
