| Dental Cleaning - Adult | $116 | 0% | $116 |
| Dental Cleaning - Child | $100 | 0% | $100 |
| Dental Exam - Comprehensive | $99 | 0% | $99 |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $171 | 0% | $171 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $251 | 0% | $251 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $202 | 0% | $202 |
| Dental Filling - White (Resin): One Surface, Anterior | $204 | 0% | $204 |
| Dental Filling - White (Resin): One Surface, Posterior | $209 | 0% | $209 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $362 | 0% | $362 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $228 | 0% | $228 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $286 | 0% | $286 |
| Flouride - Topical Varnish Application | $51 | 0% | $51 |
| Maintenance Therapy - Periodontal | $162 | 0% | $162 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $288 | 0% | $288 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $93 | 0% | $93 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $194 | 0% | $194 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | 0% | $36 |
| X-Ray - Complete Intraoral Series | $158 | 0% | $158 |
| X-Ray - Four Images, Bitewings | $83 | 0% | $83 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
| X-Ray - Two Images, Bitewings | $56 | 0% | $56 |
| X-Ray - Whole Mouth from Outside Mouth | $137 | 0% | $137 |
