| Dental Cleaning - Adult | $104 | 0% | $104 |
| Dental Cleaning - Child | $89 | 0% | $89 |
| Dental Exam - Comprehensive | $100 | 0% | $100 |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $179 | 0% | $179 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $263 | 0% | $263 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $210 | 0% | $210 |
| Dental Filling - White (Resin): One Surface, Anterior | $195 | 0% | $195 |
| Dental Filling - White (Resin): One Surface, Posterior | $179 | 0% | $179 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $263 | 0% | $263 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $235 | 0% | $235 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $210 | 0% | $210 |
| Fluoride - Topical Application | $47 | 0% | $47 |
| Maintenance Therapy - Periodontal | $142 | 0% | $142 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $341 | 0% | $341 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $107 | 0% | $107 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $65 | 0% | $65 |
| Tooth Extraction - Elevation and/or Forceps Removal | $231 | 0% | $231 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
| X-Ray - Complete Intraoral Series | $193 | 0% | $193 |
| X-Ray - Four Images, Bitewings | $83 | 0% | $83 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
| X-Ray - Two Images, Bitewings | $62 | 0% | $62 |
| X-Ray - Whole Mouth from Outside Mouth | $123 | 0% | $123 |
