| Dental Cleaning - Adult | $127 | 0% | $127 |
| Dental Cleaning - Child | $87 | 0% | $87 |
| Dental Exam - Comprehensive | $119 | 0% | $119 |
| Dental Exam - Periodic, Established Patient | $50 | 0% | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $207 | 0% | $207 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $328 | 0% | $328 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $267 | 0% | $267 |
| Dental Filling - White (Resin): One Surface, Anterior | $207 | 0% | $207 |
| Dental Filling - White (Resin): One Surface, Posterior | $207 | 0% | $207 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $357 | 0% | $357 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $267 | 0% | $267 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $357 | 0% | $357 |
| Maintenance Therapy - Periodontal | $173 | 0% | $173 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $394 | 0% | $394 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $124 | 0% | $124 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | 0% | $74 |
| Tooth Extraction - Elevation and/or Forceps Removal | $189 | 0% | $189 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
| X-Ray - Four Images, Bitewings | $87 | 0% | $87 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
| X-Ray - Two Images, Bitewings | $69 | 0% | $69 |
| X-Ray - Whole Mouth from Outside Mouth | $158 | 0% | $158 |
