| Dental Cleaning - Adult | $122 | 0% | $122 |
| Dental Cleaning - Child | $92 | 0% | $92 |
| Dental Exam - Comprehensive | $90 | 0% | $90 |
| Dental Exam - Periodic, Established Patient | $46 | 0% | $46 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $174 | 0% | $174 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $318 | 0% | $318 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $260 | 0% | $260 |
| Dental Filling - White (Resin): One Surface, Posterior | $174 | 0% | $174 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $215 | 0% | $215 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $260 | 0% | $260 |
| Flouride - Topical Varnish Application | $55 | 0% | $55 |
| Maintenance Therapy - Periodontal | $145 | 0% | $145 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $309 | 0% | $309 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | 0% | $103 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $72 | 0% | $72 |
| Tooth Extraction - Elevation and/or Forceps Removal | $189 | 0% | $189 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $23 | 0% | $23 |
| X-Ray - Complete Intraoral Series | $182 | 0% | $182 |
| X-Ray - Four Images, Bitewings | $83 | 0% | $83 |
| X-Ray - Intraoral, Periapical Radiographic Image | $30 | 0% | $30 |
| X-Ray - Two Images, Bitewings | $46 | 0% | $46 |
| X-Ray - Whole Mouth from Outside Mouth | $153 | 0% | $153 |
