| Dental Cleaning - Adult | $105 | 0% | $105 |
| Dental Cleaning - Child | $78 | 0% | $78 |
| Dental Exam - Comprehensive | $121 | 0% | $121 |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $205 | 0% | $205 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $354 | 0% | $354 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $260 | 0% | $260 |
| Dental Filling - White (Resin): One Surface, Anterior | $188 | 0% | $188 |
| Dental Filling - White (Resin): One Surface, Posterior | $203 | 0% | $203 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $347 | 0% | $347 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $216 | 0% | $216 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $257 | 0% | $257 |
| Flouride - Topical Varnish Application | $46 | 0% | $46 |
| Fluoride - Topical Application | $40 | 0% | $40 |
| Maintenance Therapy - Periodontal | $140 | 0% | $140 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $254 | 0% | $254 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $91 | 0% | $91 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $284 | 0% | $284 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
| X-Ray - Complete Intraoral Series | $141 | 0% | $141 |
| X-Ray - Four Images, Bitewings | $70 | 0% | $70 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $57 | 0% | $57 |
