| Dental Cleaning - Adult | $202 | 0% | $202 |
| Dental Cleaning - Child | $179 | 0% | $179 |
| Dental Exam - Comprehensive | $139 | 0% | $139 |
| Dental Exam - Periodic, Established Patient | $88 | 0% | $88 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $260 | 0% | $260 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $393 | 0% | $393 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $344 | 0% | $344 |
| Dental Filling - White (Resin): One Surface, Anterior | $284 | 0% | $284 |
| Dental Filling - White (Resin): One Surface, Posterior | $342 | 0% | $342 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $599 | 0% | $599 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $355 | 0% | $355 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $468 | 0% | $468 |
| Flouride - Topical Varnish Application | $74 | 0% | $74 |
| Maintenance Therapy - Periodontal | $231 | 0% | $231 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $540 | 0% | $540 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $139 | 0% | $139 |
| Tooth Extraction - Elevation and/or Forceps Removal | $260 | 0% | $260 |
| X-Ray - Complete Intraoral Series | $252 | 0% | $252 |
| X-Ray - Four Images, Bitewings | $139 | 0% | $139 |
| X-Ray - Intraoral, Periapical Radiographic Image | $61 | 0% | $61 |
| X-Ray - Two Images, Bitewings | $101 | 0% | $101 |
| X-Ray - Whole Mouth from Outside Mouth | $217 | 0% | $217 |
