| Dental Cleaning - Adult | $118 | 0% | $118 |
| Dental Cleaning - Child | $86 | 0% | $86 |
| Dental Exam - Comprehensive | $182 | 0% | $182 |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $242 | 0% | $242 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $383 | 0% | $383 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $297 | 0% | $297 |
| Dental Filling - White (Resin): One Surface, Anterior | $217 | 0% | $217 |
| Dental Filling - White (Resin): One Surface, Posterior | $254 | 0% | $254 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $383 | 0% | $383 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $281 | 0% | $281 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $312 | 0% | $312 |
| Fluoride - Topical Application | $49 | 0% | $49 |
| Maintenance Therapy - Periodontal | $205 | 0% | $205 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $312 | 0% | $312 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $110 | 0% | $110 |
| Tooth Extraction - Elevation and/or Forceps Removal | $289 | 0% | $289 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $39 | 0% | $39 |
| X-Ray - Complete Intraoral Series | $182 | 0% | $182 |
| X-Ray - Four Images, Bitewings | $98 | 0% | $98 |
| X-Ray - Intraoral, Periapical Radiographic Image | $49 | 0% | $49 |
| X-Ray - Two Images, Bitewings | $74 | 0% | $74 |
| X-Ray - Whole Mouth from Outside Mouth | $180 | 0% | $180 |
