| Dental Cleaning - Adult | $125 | 0% | $125 |
| Dental Cleaning - Child | $101 | 0% | $101 |
| Dental Exam - Comprehensive | $167 | 0% | $167 |
| Dental Exam - Periodic, Established Patient | $64 | 0% | $64 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $324 | 0% | $324 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $463 | 0% | $463 |
| Dental Filling - White (Resin): One Surface, Anterior | $229 | 0% | $229 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $463 | 0% | $463 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $259 | 0% | $259 |
| Flouride - Topical Varnish Application | $49 | 0% | $49 |
| Maintenance Therapy - Periodontal | $181 | 0% | $181 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $330 | 0% | $330 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $131 | 0% | $131 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | 0% | $71 |
| Tooth Extraction - Elevation and/or Forceps Removal | $218 | 0% | $218 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | 0% | $38 |
| X-Ray - Complete Intraoral Series | $174 | 0% | $174 |
| X-Ray - Four Images, Bitewings | $86 | 0% | $86 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
| X-Ray - Two Images, Bitewings | $64 | 0% | $64 |
| X-Ray - Whole Mouth from Outside Mouth | $156 | 0% | $156 |
