| Dental Cleaning - Adult | $153 | 0% | $153 |
| Dental Cleaning - Child | $124 | 0% | $124 |
| Dental Exam - Comprehensive | $161 | 0% | $161 |
| Dental Exam - Periodic, Established Patient | $71 | 0% | $71 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $267 | 0% | $267 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $515 | 0% | $515 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $412 | 0% | $412 |
| Dental Filling - White (Resin): One Surface, Anterior | $258 | 0% | $258 |
| Dental Filling - White (Resin): One Surface, Posterior | $271 | 0% | $271 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $540 | 0% | $540 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $412 | 0% | $412 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $412 | 0% | $412 |
| Flouride - Topical Varnish Application | $43 | 0% | $43 |
| Maintenance Therapy - Periodontal | $173 | 0% | $173 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $379 | 0% | $379 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $108 | 0% | $108 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $75 | 0% | $75 |
| Tooth Extraction - Elevation and/or Forceps Removal | $265 | 0% | $265 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
| X-Ray - Complete Intraoral Series | $230 | 0% | $230 |
| X-Ray - Four Images, Bitewings | $99 | 0% | $99 |
| X-Ray - Intraoral, Periapical Radiographic Image | $60 | 0% | $60 |
| X-Ray - Two Images, Bitewings | $93 | 0% | $93 |
| X-Ray - Whole Mouth from Outside Mouth | $188 | 0% | $188 |
