| Dental Cleaning - Adult | $133 | 0% | $133 |
| Dental Cleaning - Child | $120 | 0% | $120 |
| Dental Exam - Comprehensive | $120 | 0% | $120 |
| Dental Exam - Periodic, Established Patient | $74 | 0% | $74 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $246 | 0% | $246 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $379 | 0% | $379 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $312 | 0% | $312 |
| Dental Filling - White (Resin): One Surface, Anterior | $216 | 0% | $216 |
| Dental Filling - White (Resin): One Surface, Posterior | $233 | 0% | $233 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $379 | 0% | $379 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | 0% | $271 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $312 | 0% | $312 |
| Flouride - Topical Varnish Application | $60 | 0% | $60 |
| Fluoride - Topical Application | $55 | 0% | $55 |
| Maintenance Therapy - Periodontal | $193 | 0% | $193 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $340 | 0% | $340 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $113 | 0% | $113 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $76 | 0% | $76 |
| Tooth Extraction - Elevation and/or Forceps Removal | $260 | 0% | $260 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $17 | 0% | $17 |
| X-Ray - Complete Intraoral Series | $184 | 0% | $184 |
| X-Ray - Four Images, Bitewings | $88 | 0% | $88 |
| X-Ray - Intraoral, Periapical Radiographic Image | $41 | 0% | $41 |
| X-Ray - Two Images, Bitewings | $76 | 0% | $76 |
| X-Ray - Whole Mouth from Outside Mouth | $185 | 0% | $185 |
