| Dental Cleaning - Adult | $189 | 0% | $189 |
| Dental Cleaning - Child | $145 | 0% | $145 |
| Dental Exam - Comprehensive | $145 | 0% | $145 |
| Dental Exam - Periodic, Established Patient | $88 | 0% | $88 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $230 | 0% | $230 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $358 | 0% | $358 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $298 | 0% | $298 |
| Dental Filling - White (Resin): One Surface, Anterior | $194 | 0% | $194 |
| Dental Filling - White (Resin): One Surface, Posterior | $209 | 0% | $209 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $473 | 0% | $473 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $328 | 0% | $328 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $343 | 0% | $343 |
| Fluoride - Topical Application | $84 | 0% | $84 |
| Maintenance Therapy - Periodontal | $212 | 0% | $212 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $137 | 0% | $137 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $97 | 0% | $97 |
| Tooth Extraction - Elevation and/or Forceps Removal | $260 | 0% | $260 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $21 | 0% | $21 |
| X-Ray - Complete Intraoral Series | $265 | 0% | $265 |
| X-Ray - Four Images, Bitewings | $113 | 0% | $113 |
| X-Ray - Intraoral, Periapical Radiographic Image | $61 | 0% | $61 |
| X-Ray - Two Images, Bitewings | $92 | 0% | $92 |
| X-Ray - Whole Mouth from Outside Mouth | $223 | 0% | $223 |
