| Dental Cleaning - Adult | $120 | 0% | $120 |
| Dental Cleaning - Child | $89 | 0% | $89 |
| Dental Exam - Comprehensive | $118 | 0% | $118 |
| Dental Exam - Periodic, Established Patient | $68 | 0% | $68 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $230 | 0% | $230 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $391 | 0% | $391 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $307 | 0% | $307 |
| Dental Filling - White (Resin): One Surface, Anterior | $211 | 0% | $211 |
| Dental Filling - White (Resin): One Surface, Posterior | $230 | 0% | $230 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $375 | 0% | $375 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $263 | 0% | $263 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $307 | 0% | $307 |
| Flouride - Topical Varnish Application | $40 | 0% | $40 |
| Maintenance Therapy - Periodontal | $177 | 0% | $177 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $316 | 0% | $316 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | 0% | $101 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | 0% | $74 |
| Tooth Extraction - Elevation and/or Forceps Removal | $339 | 0% | $339 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | 0% | $33 |
| X-Ray - Complete Intraoral Series | $171 | 0% | $171 |
| X-Ray - Four Images, Bitewings | $85 | 0% | $85 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
| X-Ray - Two Images, Bitewings | $60 | 0% | $60 |
| X-Ray - Whole Mouth from Outside Mouth | $147 | 0% | $147 |
