| Dental Cleaning - Adult | $163 | 0% | $163 |
| Dental Cleaning - Child | $131 | 0% | $131 |
| Dental Exam - Comprehensive | $126 | 0% | $126 |
| Dental Exam - Periodic, Established Patient | $68 | 0% | $68 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $247 | 0% | $247 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $294 | 0% | $294 |
| Dental Filling - White (Resin): One Surface, Anterior | $198 | 0% | $198 |
| Dental Filling - White (Resin): One Surface, Posterior | $247 | 0% | $247 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $368 | 0% | $368 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $294 | 0% | $294 |
| Flouride - Topical Varnish Application | $58 | 0% | $58 |
| Maintenance Therapy - Periodontal | $205 | 0% | $205 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $137 | 0% | $137 |
| Tooth Extraction - Elevation and/or Forceps Removal | $242 | 0% | $242 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $47 | 0% | $47 |
| X-Ray - Complete Intraoral Series | $189 | 0% | $189 |
| X-Ray - Four Images, Bitewings | $100 | 0% | $100 |
| X-Ray - Intraoral, Periapical Radiographic Image | $58 | 0% | $58 |
| X-Ray - Two Images, Bitewings | $82 | 0% | $82 |
