| Dental Cleaning - Adult | $104 | 0% | $104 |
| Dental Cleaning - Child | $78 | 0% | $78 |
| Dental Exam - Comprehensive | $90 | 0% | $90 |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $168 | 0% | $168 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $252 | 0% | $252 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $215 | 0% | $215 |
| Dental Filling - White (Resin): One Surface, Anterior | $166 | 0% | $166 |
| Dental Filling - White (Resin): One Surface, Posterior | $168 | 0% | $168 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $252 | 0% | $252 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $213 | 0% | $213 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $215 | 0% | $215 |
| Flouride - Topical Varnish Application | $86 | 0% | $86 |
| Fluoride - Topical Application | $43 | 0% | $43 |
| Maintenance Therapy - Periodontal | $307 | 0% | $307 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $87 | 0% | $87 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | 0% | $61 |
| Tooth Extraction - Elevation and/or Forceps Removal | $200 | 0% | $200 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
| X-Ray - Complete Intraoral Series | $145 | 0% | $145 |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
| X-Ray - Two Images, Bitewings | $56 | 0% | $56 |
