| Dental Cleaning - Adult | $138 | 0% | $138 |
| Dental Cleaning - Child | $120 | 0% | $120 |
| Dental Exam - Comprehensive | $122 | 0% | $122 |
| Dental Exam - Periodic, Established Patient | $75 | 0% | $75 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $238 | 0% | $238 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $366 | 0% | $366 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $296 | 0% | $296 |
| Dental Filling - White (Resin): One Surface, Anterior | $215 | 0% | $215 |
| Dental Filling - White (Resin): One Surface, Posterior | $233 | 0% | $233 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $391 | 0% | $391 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | 0% | $271 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $321 | 0% | $321 |
| Flouride - Topical Varnish Application | $66 | 0% | $66 |
| Maintenance Therapy - Periodontal | $197 | 0% | $197 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $395 | 0% | $395 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $111 | 0% | $111 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $81 | 0% | $81 |
| Tooth Extraction - Elevation and/or Forceps Removal | $260 | 0% | $260 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
| X-Ray - Complete Intraoral Series | $188 | 0% | $188 |
| X-Ray - Four Images, Bitewings | $96 | 0% | $96 |
| X-Ray - Intraoral, Periapical Radiographic Image | $43 | 0% | $43 |
| X-Ray - Two Images, Bitewings | $76 | 0% | $76 |
