| Dental Cleaning - Adult | $112 | 0% | $112 |
| Dental Cleaning - Child | $86 | 0% | $86 |
| Dental Exam - Comprehensive | $110 | 0% | $110 |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $210 | 0% | $210 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $296 | 0% | $296 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $260 | 0% | $260 |
| Dental Filling - White (Resin): One Surface, Anterior | $221 | 0% | $221 |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | 0% | $221 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $344 | 0% | $344 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $252 | 0% | $252 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $279 | 0% | $279 |
| Flouride - Topical Varnish Application | $57 | 0% | $57 |
| Fluoride - Topical Application | $54 | 0% | $54 |
| Maintenance Therapy - Periodontal | $184 | 0% | $184 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $307 | 0% | $307 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $75 | 0% | $75 |
| Tooth Extraction - Elevation and/or Forceps Removal | $315 | 0% | $315 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Complete Intraoral Series | $222 | 0% | $222 |
| X-Ray - Four Images, Bitewings | $80 | 0% | $80 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
| X-Ray - Two Images, Bitewings | $56 | 0% | $56 |
| X-Ray - Whole Mouth from Outside Mouth | $142 | 0% | $142 |
