| Dental Cleaning - Adult | $139 | 0% | $139 |
| Dental Cleaning - Child | $92 | 0% | $92 |
| Dental Exam - Periodic, Established Patient | $62 | 0% | $62 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $326 | 0% | $326 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $405 | 0% | $405 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $378 | 0% | $378 |
| Dental Filling - White (Resin): One Surface, Posterior | $326 | 0% | $326 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $411 | 0% | $411 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $389 | 0% | $389 |
| Flouride - Topical Varnish Application | $42 | 0% | $42 |
| Fluoride - Topical Application | $43 | 0% | $43 |
| Maintenance Therapy - Periodontal | $271 | 0% | $271 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $394 | 0% | $394 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $130 | 0% | $130 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $81 | 0% | $81 |
| Tooth Extraction - Elevation and/or Forceps Removal | $374 | 0% | $374 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $23 | 0% | $23 |
| X-Ray - Complete Intraoral Series | $170 | 0% | $170 |
| X-Ray - Four Images, Bitewings | $68 | 0% | $68 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $45 | 0% | $45 |
