| Dental Cleaning - Adult | $109 | 0% | $109 |
| Dental Cleaning - Child | $85 | 0% | $85 |
| Dental Exam - Comprehensive | $92 | 0% | $92 |
| Dental Exam - Periodic, Established Patient | $50 | 0% | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $277 | 0% | $277 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $348 | 0% | $348 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $290 | 0% | $290 |
| Dental Filling - White (Resin): One Surface, Anterior | $202 | 0% | $202 |
| Dental Filling - White (Resin): One Surface, Posterior | $237 | 0% | $237 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $533 | 0% | $533 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $254 | 0% | $254 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $290 | 0% | $290 |
| Flouride - Topical Varnish Application | $43 | 0% | $43 |
| Maintenance Therapy - Periodontal | $169 | 0% | $169 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $102 | 0% | $102 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $221 | 0% | $221 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $41 | 0% | $41 |
| X-Ray - Four Images, Bitewings | $74 | 0% | $74 |
| X-Ray - Intraoral, Periapical Radiographic Image | $49 | 0% | $49 |
| X-Ray - Two Images, Bitewings | $51 | 0% | $51 |
| X-Ray - Whole Mouth from Outside Mouth | $129 | 0% | $129 |
