| Dental Cleaning - Adult | $134 | 0% | $134 |
| Dental Cleaning - Child | $91 | 0% | $91 |
| Dental Exam - Comprehensive | $206 | 0% | $206 |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $279 | 0% | $279 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $365 | 0% | $365 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $302 | 0% | $302 |
| Dental Filling - White (Resin): One Surface, Anterior | $211 | 0% | $211 |
| Dental Filling - White (Resin): One Surface, Posterior | $247 | 0% | $247 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $461 | 0% | $461 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $268 | 0% | $268 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $359 | 0% | $359 |
| Flouride - Topical Varnish Application | $49 | 0% | $49 |
| Fluoride - Topical Application | $67 | 0% | $67 |
| Maintenance Therapy - Periodontal | $161 | 0% | $161 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $354 | 0% | $354 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $113 | 0% | $113 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $76 | 0% | $76 |
| Tooth Extraction - Elevation and/or Forceps Removal | $270 | 0% | $270 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $24 | 0% | $24 |
| X-Ray - Complete Intraoral Series | $208 | 0% | $208 |
| X-Ray - Four Images, Bitewings | $92 | 0% | $92 |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | 0% | $46 |
| X-Ray - Two Images, Bitewings | $58 | 0% | $58 |
| X-Ray - Whole Mouth from Outside Mouth | $135 | 0% | $135 |
