| Dental Cleaning - Adult | $102 | 0% | $102 |
| Dental Cleaning - Child | $87 | 0% | $87 |
| Dental Exam - Comprehensive | $90 | 0% | $90 |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $244 | 0% | $244 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $422 | 0% | $422 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $221 | 0% | $221 |
| Dental Filling - White (Resin): One Surface, Anterior | $163 | 0% | $163 |
| Dental Filling - White (Resin): One Surface, Posterior | $163 | 0% | $163 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $281 | 0% | $281 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $221 | 0% | $221 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $221 | 0% | $221 |
| Fluoride - Topical Application | $38 | 0% | $38 |
| Maintenance Therapy - Periodontal | $130 | 0% | $130 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $259 | 0% | $259 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $90 | 0% | $90 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | 0% | $61 |
| Tooth Extraction - Elevation and/or Forceps Removal | $269 | 0% | $269 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | 0% | $30 |
| X-Ray - Complete Intraoral Series | $233 | 0% | $233 |
| X-Ray - Four Images, Bitewings | $86 | 0% | $86 |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
| X-Ray - Whole Mouth from Outside Mouth | $147 | 0% | $147 |
