| Dental Cleaning - Adult | $118 | 0% | $118 |
| Dental Cleaning - Child | $91 | 0% | $91 |
| Dental Exam - Comprehensive | $108 | 0% | $108 |
| Dental Exam - Periodic, Established Patient | $65 | 0% | $65 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $188 | 0% | $188 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $266 | 0% | $266 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $227 | 0% | $227 |
| Dental Filling - White (Resin): One Surface, Anterior | $216 | 0% | $216 |
| Dental Filling - White (Resin): One Surface, Posterior | $245 | 0% | $245 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $380 | 0% | $380 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $248 | 0% | $248 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $293 | 0% | $293 |
| Fluoride - Topical Application | $48 | 0% | $48 |
| Maintenance Therapy - Periodontal | $167 | 0% | $167 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $327 | 0% | $327 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $144 | 0% | $144 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $66 | 0% | $66 |
| Tooth Extraction - Elevation and/or Forceps Removal | $202 | 0% | $202 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
| X-Ray - Complete Intraoral Series | $179 | 0% | $179 |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
| X-Ray - Two Images, Bitewings | $65 | 0% | $65 |
| X-Ray - Whole Mouth from Outside Mouth | $179 | 0% | $179 |
