| Dental Cleaning - Adult | $144 | 0% | $144 |
| Dental Cleaning - Child | $106 | 0% | $106 |
| Dental Exam - Comprehensive | $116 | 0% | $116 |
| Dental Exam - Periodic, Established Patient | $66 | 0% | $66 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $229 | 0% | $229 |
| Dental Filling - White (Resin): One Surface, Anterior | $202 | 0% | $202 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $416 | 0% | $416 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $260 | 0% | $260 |
| Maintenance Therapy - Periodontal | $185 | 0% | $185 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $333 | 0% | $333 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $111 | 0% | $111 |
| Tooth Extraction - Elevation and/or Forceps Removal | $452 | 0% | $452 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $43 | 0% | $43 |
| X-Ray - Complete Intraoral Series | $193 | 0% | $193 |
| X-Ray - Four Images, Bitewings | $93 | 0% | $93 |
| X-Ray - Intraoral, Periapical Radiographic Image | $45 | 0% | $45 |
| X-Ray - Two Images, Bitewings | $68 | 0% | $68 |
| X-Ray - Whole Mouth from Outside Mouth | $163 | 0% | $163 |
