| Dental Cleaning - Adult | $118 | 0% | $118 |
| Dental Cleaning - Child | $98 | 0% | $98 |
| Dental Exam - Comprehensive | $131 | 0% | $131 |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $222 | 0% | $222 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $302 | 0% | $302 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $284 | 0% | $284 |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | 0% | $184 |
| Dental Filling - White (Resin): One Surface, Posterior | $203 | 0% | $203 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $369 | 0% | $369 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $256 | 0% | $256 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $284 | 0% | $284 |
| Flouride - Topical Varnish Application | $44 | 0% | $44 |
| Fluoride - Topical Application | $46 | 0% | $46 |
| Maintenance Therapy - Periodontal | $163 | 0% | $163 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $297 | 0% | $297 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $97 | 0% | $97 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $327 | 0% | $327 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | 0% | $30 |
| X-Ray - Complete Intraoral Series | $206 | 0% | $206 |
| X-Ray - Four Images, Bitewings | $77 | 0% | $77 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
| X-Ray - Two Images, Bitewings | $55 | 0% | $55 |
| X-Ray - Whole Mouth from Outside Mouth | $140 | 0% | $140 |
