| Dental Cleaning - Adult | $107 | 0% | $107 |
| Dental Cleaning - Child | $86 | 0% | $86 |
| Dental Exam - Comprehensive | $91 | 0% | $91 |
| Dental Exam - Periodic, Established Patient | $50 | 0% | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $194 | 0% | $194 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $357 | 0% | $357 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | 0% | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $167 | 0% | $167 |
| Dental Filling - White (Resin): One Surface, Posterior | $194 | 0% | $194 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $357 | 0% | $357 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $205 | 0% | $205 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
| Fluoride - Topical Application | $43 | 0% | $43 |
| Maintenance Therapy - Periodontal | $156 | 0% | $156 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $311 | 0% | $311 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | 0% | $88 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | 0% | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $331 | 0% | $331 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $51 | 0% | $51 |
