| Dental Cleaning - Adult | $130 | 0% | $130 |
| Dental Cleaning - Child | $92 | 0% | $92 |
| Dental Exam - Comprehensive | $163 | 0% | $163 |
| Dental Exam - Periodic, Established Patient | $65 | 0% | $65 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $320 | 0% | $320 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $509 | 0% | $509 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $420 | 0% | $420 |
| Dental Filling - White (Resin): One Surface, Anterior | $299 | 0% | $299 |
| Dental Filling - White (Resin): One Surface, Posterior | $320 | 0% | $320 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $509 | 0% | $509 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $341 | 0% | $341 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $425 | 0% | $425 |
| Fluoride - Topical Application | $49 | 0% | $49 |
| Maintenance Therapy - Periodontal | $165 | 0% | $165 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $341 | 0% | $341 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $102 | 0% | $102 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $62 | 0% | $62 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
| X-Ray - Complete Intraoral Series | $160 | 0% | $160 |
| X-Ray - Four Images, Bitewings | $75 | 0% | $75 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
| X-Ray - Two Images, Bitewings | $56 | 0% | $56 |
