| Dental Cleaning - Adult | $105 | 0% | $105 |
| Dental Cleaning - Child | $85 | 0% | $85 |
| Dental Exam - Comprehensive | $105 | 0% | $105 |
| Dental Exam - Periodic, Established Patient | $61 | 0% | $61 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $218 | 0% | $218 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | 0% | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $278 | 0% | $278 |
| Dental Filling - White (Resin): One Surface, Anterior | $212 | 0% | $212 |
| Dental Filling - White (Resin): One Surface, Posterior | $218 | 0% | $218 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $278 | 0% | $278 |
| Flouride - Topical Varnish Application | $56 | 0% | $56 |
| Fluoride - Topical Application | $45 | 0% | $45 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | 0% | $71 |
| Tooth Extraction - Elevation and/or Forceps Removal | $224 | 0% | $224 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | 0% | $30 |
| X-Ray - Complete Intraoral Series | $190 | 0% | $190 |
| X-Ray - Four Images, Bitewings | $79 | 0% | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | 0% | $36 |
| X-Ray - Two Images, Bitewings | $56 | 0% | $56 |
| X-Ray - Whole Mouth from Outside Mouth | $134 | 0% | $134 |
