| Dental Cleaning - Adult | $103 | 0% | $103 |
| Dental Cleaning - Child | $84 | 0% | $84 |
| Dental Exam - Comprehensive | $117 | 0% | $117 |
| Dental Exam - Periodic, Established Patient | $50 | 0% | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $205 | 0% | $205 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $321 | 0% | $321 |
| Dental Filling - White (Resin): One Surface, Anterior | $376 | 0% | $376 |
| Dental Filling - White (Resin): One Surface, Posterior | $185 | 0% | $185 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $487 | 0% | $487 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $204 | 0% | $204 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $259 | 0% | $259 |
| Fluoride - Topical Application | $44 | 0% | $44 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $246 | 0% | $246 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $90 | 0% | $90 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | 0% | $184 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $51 | 0% | $51 |
| X-Ray - Whole Mouth from Outside Mouth | $140 | 0% | $140 |
