| Dental Cleaning - Adult | $104 | 0% | $104 |
| Dental Cleaning - Child | $79 | 0% | $79 |
| Dental Exam - Comprehensive | $90 | 0% | $90 |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $149 | 0% | $149 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $221 | 0% | $221 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $181 | 0% | $181 |
| Dental Filling - White (Resin): One Surface, Anterior | $164 | 0% | $164 |
| Dental Filling - White (Resin): One Surface, Posterior | $188 | 0% | $188 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $315 | 0% | $315 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $201 | 0% | $201 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $261 | 0% | $261 |
| Flouride - Topical Varnish Application | $41 | 0% | $41 |
| Fluoride - Topical Application | $41 | 0% | $41 |
| Maintenance Therapy - Periodontal | $150 | 0% | $150 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $275 | 0% | $275 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $63 | 0% | $63 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $182 | 0% | $182 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
| X-Ray - Complete Intraoral Series | $186 | 0% | $186 |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
| X-Ray - Whole Mouth from Outside Mouth | $128 | 0% | $128 |
