| Dental Cleaning - Adult | $119 | 0% | $119 |
| Dental Cleaning - Child | $91 | 0% | $91 |
| Dental Exam - Comprehensive | $104 | 0% | $104 |
| Dental Exam - Periodic, Established Patient | $55 | 0% | $55 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $180 | 0% | $180 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $348 | 0% | $348 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $286 | 0% | $286 |
| Dental Filling - White (Resin): One Surface, Anterior | $179 | 0% | $179 |
| Dental Filling - White (Resin): One Surface, Posterior | $180 | 0% | $180 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $371 | 0% | $371 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $218 | 0% | $218 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $286 | 0% | $286 |
| Flouride - Topical Varnish Application | $50 | 0% | $50 |
| Fluoride - Topical Application | $47 | 0% | $47 |
| Maintenance Therapy - Periodontal | $164 | 0% | $164 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $299 | 0% | $299 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | 0% | $103 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $156 | 0% | $156 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | 0% | $30 |
| X-Ray - Complete Intraoral Series | $159 | 0% | $159 |
| X-Ray - Four Images, Bitewings | $78 | 0% | $78 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
| X-Ray - Two Images, Bitewings | $56 | 0% | $56 |
