| Dental Cleaning - Adult | $87 | 0% | $87 |
| Dental Cleaning - Child | $87 | 0% | $87 |
| Dental Exam - Comprehensive | $120 | 0% | $120 |
| Dental Exam - Periodic, Established Patient | $42 | 0% | $42 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $269 | 0% | $269 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $368 | 0% | $368 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $314 | 0% | $314 |
| Dental Filling - White (Resin): One Surface, Anterior | $171 | 0% | $171 |
| Dental Filling - White (Resin): One Surface, Posterior | $278 | 0% | $278 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $318 | 0% | $318 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $216 | 0% | $216 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $468 | 0% | $468 |
| Flouride - Topical Varnish Application | $51 | 0% | $51 |
| Fluoride - Topical Application | $37 | 0% | $37 |
| Maintenance Therapy - Periodontal | $151 | 0% | $151 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $383 | 0% | $383 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $106 | 0% | $106 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | 0% | $60 |
| Tooth Extraction - Elevation and/or Forceps Removal | $233 | 0% | $233 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | 0% | $30 |
| X-Ray - Complete Intraoral Series | $218 | 0% | $218 |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | 0% | $36 |
| X-Ray - Two Images, Bitewings | $43 | 0% | $43 |
| X-Ray - Whole Mouth from Outside Mouth | $110 | 0% | $110 |
