| Dental Cleaning - Adult | $104 | 0% | $104 |
| Dental Cleaning - Child | $116 | 0% | $116 |
| Dental Exam - Comprehensive | $100 | 0% | $100 |
| Dental Exam - Periodic, Established Patient | $74 | 0% | $74 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $194 | 0% | $194 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $268 | 0% | $268 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $252 | 0% | $252 |
| Dental Filling - White (Resin): One Surface, Anterior | $177 | 0% | $177 |
| Dental Filling - White (Resin): One Surface, Posterior | $194 | 0% | $194 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $391 | 0% | $391 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $218 | 0% | $218 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $261 | 0% | $261 |
| Flouride - Topical Varnish Application | $47 | 0% | $47 |
| Fluoride - Topical Application | $44 | 0% | $44 |
| Maintenance Therapy - Periodontal | $212 | 0% | $212 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $278 | 0% | $278 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $86 | 0% | $86 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | 0% | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $194 | 0% | $194 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $17 | 0% | $17 |
| X-Ray - Complete Intraoral Series | $197 | 0% | $197 |
| X-Ray - Four Images, Bitewings | $95 | 0% | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $76 | 0% | $76 |
| X-Ray - Whole Mouth from Outside Mouth | $185 | 0% | $185 |
