| Dental Cleaning - Adult | $134 | 0% | $134 |
| Dental Cleaning - Child | $105 | 0% | $105 |
| Dental Exam - Comprehensive | $126 | 0% | $126 |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $263 | 0% | $263 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $518 | 0% | $518 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $323 | 0% | $323 |
| Dental Filling - White (Resin): One Surface, Anterior | $255 | 0% | $255 |
| Dental Filling - White (Resin): One Surface, Posterior | $223 | 0% | $223 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $372 | 0% | $372 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $305 | 0% | $305 |
| Flouride - Topical Varnish Application | $53 | 0% | $53 |
| Maintenance Therapy - Periodontal | $194 | 0% | $194 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $341 | 0% | $341 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $110 | 0% | $110 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | 0% | $74 |
| Tooth Extraction - Elevation and/or Forceps Removal | $236 | 0% | $236 |
| X-Ray - Four Images, Bitewings | $95 | 0% | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $47 | 0% | $47 |
| X-Ray - Two Images, Bitewings | $58 | 0% | $58 |
| X-Ray - Whole Mouth from Outside Mouth | $178 | 0% | $178 |
