| Dental Cleaning - Adult | $105 | 0% | $105 |
| Dental Cleaning - Child | $84 | 0% | $84 |
| Dental Exam - Comprehensive | $87 | 0% | $87 |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $125 | 0% | $125 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $567 | 0% | $567 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $449 | 0% | $449 |
| Dental Filling - White (Resin): One Surface, Anterior | $151 | 0% | $151 |
| Dental Filling - White (Resin): One Surface, Posterior | $156 | 0% | $156 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $284 | 0% | $284 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $228 | 0% | $228 |
| Flouride - Topical Varnish Application | $58 | 0% | $58 |
| Fluoride - Topical Application | $47 | 0% | $47 |
| Maintenance Therapy - Periodontal | $210 | 0% | $210 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | 0% | $92 |
| Tooth Extraction - Elevation and/or Forceps Removal | $156 | 0% | $156 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $21 | 0% | $21 |
| X-Ray - Complete Intraoral Series | $149 | 0% | $149 |
| X-Ray - Four Images, Bitewings | $68 | 0% | $68 |
| X-Ray - Intraoral, Periapical Radiographic Image | $30 | 0% | $30 |
| X-Ray - Two Images, Bitewings | $51 | 0% | $51 |
