| Dental Cleaning - Adult | $133 | 0% | $133 |
| Dental Cleaning - Child | $96 | 0% | $96 |
| Dental Exam - Comprehensive | $117 | 0% | $117 |
| Dental Exam - Periodic, Established Patient | $70 | 0% | $70 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $344 | 0% | $344 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $377 | 0% | $377 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $435 | 0% | $435 |
| Dental Filling - White (Resin): One Surface, Anterior | $221 | 0% | $221 |
| Dental Filling - White (Resin): One Surface, Posterior | $236 | 0% | $236 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $377 | 0% | $377 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $267 | 0% | $267 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $309 | 0% | $309 |
| Flouride - Topical Varnish Application | $62 | 0% | $62 |
| Maintenance Therapy - Periodontal | $193 | 0% | $193 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $339 | 0% | $339 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $107 | 0% | $107 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $77 | 0% | $77 |
| Tooth Extraction - Elevation and/or Forceps Removal | $251 | 0% | $251 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | 0% | $38 |
| X-Ray - Complete Intraoral Series | $208 | 0% | $208 |
| X-Ray - Four Images, Bitewings | $93 | 0% | $93 |
| X-Ray - Intraoral, Periapical Radiographic Image | $45 | 0% | $45 |
| X-Ray - Two Images, Bitewings | $67 | 0% | $67 |
