| Dental Cleaning - Adult | $140 | 0% | $140 |
| Dental Cleaning - Child | $112 | 0% | $112 |
| Dental Exam - Comprehensive | $109 | 0% | $109 |
| Dental Exam - Periodic, Established Patient | $74 | 0% | $74 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $198 | 0% | $198 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $314 | 0% | $314 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $254 | 0% | $254 |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | 0% | $184 |
| Dental Filling - White (Resin): One Surface, Posterior | $319 | 0% | $319 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $414 | 0% | $414 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $275 | 0% | $275 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $360 | 0% | $360 |
| Flouride - Topical Varnish Application | $58 | 0% | $58 |
| Fluoride - Topical Application | $49 | 0% | $49 |
| Maintenance Therapy - Periodontal | $173 | 0% | $173 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $300 | 0% | $300 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $86 | 0% | $86 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $91 | 0% | $91 |
| Tooth Extraction - Elevation and/or Forceps Removal | $352 | 0% | $352 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
| X-Ray - Complete Intraoral Series | $201 | 0% | $201 |
| X-Ray - Four Images, Bitewings | $103 | 0% | $103 |
| X-Ray - Intraoral, Periapical Radiographic Image | $33 | 0% | $33 |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
| X-Ray - Whole Mouth from Outside Mouth | $158 | 0% | $158 |
