| Dental Cleaning - Adult | $120 | 0% | $120 |
| Dental Cleaning - Child | $96 | 0% | $96 |
| Dental Exam - Comprehensive | $105 | 0% | $105 |
| Dental Exam - Periodic, Established Patient | $57 | 0% | $57 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $312 | 0% | $312 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $306 | 0% | $306 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $289 | 0% | $289 |
| Dental Filling - White (Resin): One Surface, Anterior | $215 | 0% | $215 |
| Dental Filling - White (Resin): One Surface, Posterior | $208 | 0% | $208 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $417 | 0% | $417 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $273 | 0% | $273 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $299 | 0% | $299 |
| Flouride - Topical Varnish Application | $45 | 0% | $45 |
| Fluoride - Topical Application | $45 | 0% | $45 |
| Maintenance Therapy - Periodontal | $201 | 0% | $201 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $106 | 0% | $106 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $78 | 0% | $78 |
| Tooth Extraction - Elevation and/or Forceps Removal | $263 | 0% | $263 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $52 | 0% | $52 |
| X-Ray - Complete Intraoral Series | $181 | 0% | $181 |
| X-Ray - Four Images, Bitewings | $100 | 0% | $100 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
| X-Ray - Two Images, Bitewings | $60 | 0% | $60 |
| X-Ray - Whole Mouth from Outside Mouth | $182 | 0% | $182 |
