| Dental Cleaning - Adult | $167 | 0% | $167 |
| Dental Cleaning - Child | $122 | 0% | $122 |
| Dental Exam - Comprehensive | $86 | 0% | $86 |
| Dental Exam - Periodic, Established Patient | $69 | 0% | $69 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $292 | 0% | $292 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $439 | 0% | $439 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $381 | 0% | $381 |
| Dental Filling - White (Resin): One Surface, Anterior | $255 | 0% | $255 |
| Dental Filling - White (Resin): One Surface, Posterior | $306 | 0% | $306 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $421 | 0% | $421 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $300 | 0% | $300 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $366 | 0% | $366 |
| Maintenance Therapy - Periodontal | $187 | 0% | $187 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $444 | 0% | $444 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $124 | 0% | $124 |
| Tooth Extraction - Elevation and/or Forceps Removal | $397 | 0% | $397 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $41 | 0% | $41 |
| X-Ray - Complete Intraoral Series | $322 | 0% | $322 |
| X-Ray - Four Images, Bitewings | $106 | 0% | $106 |
| X-Ray - Intraoral, Periapical Radiographic Image | $51 | 0% | $51 |
| X-Ray - Two Images, Bitewings | $87 | 0% | $87 |
| X-Ray - Whole Mouth from Outside Mouth | $223 | 0% | $223 |
