| Dental Cleaning - Adult | $145 | 0% | $145 |
| Dental Cleaning - Child | $118 | 0% | $118 |
| Dental Exam - Comprehensive | $133 | 0% | $133 |
| Dental Exam - Periodic, Established Patient | $69 | 0% | $69 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $185 | 0% | $185 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $290 | 0% | $290 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $227 | 0% | $227 |
| Dental Filling - White (Resin): One Surface, Anterior | $223 | 0% | $223 |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | 0% | $221 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $370 | 0% | $370 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | 0% | $271 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $300 | 0% | $300 |
| Flouride - Topical Varnish Application | $61 | 0% | $61 |
| Maintenance Therapy - Periodontal | $193 | 0% | $193 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $93 | 0% | $93 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | 0% | $69 |
| Tooth Extraction - Elevation and/or Forceps Removal | $191 | 0% | $191 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
| X-Ray - Complete Intraoral Series | $197 | 0% | $197 |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $60 | 0% | $60 |
| X-Ray - Whole Mouth from Outside Mouth | $170 | 0% | $170 |
