| Dental Cleaning - Adult | $108 | 0% | $108 |
| Dental Cleaning - Child | $87 | 0% | $87 |
| Dental Exam - Comprehensive | $120 | 0% | $120 |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $176 | 0% | $176 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | 0% | $326 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $272 | 0% | $272 |
| Dental Filling - White (Resin): One Surface, Posterior | $216 | 0% | $216 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $354 | 0% | $354 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $212 | 0% | $212 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $272 | 0% | $272 |
| Fluoride - Topical Application | $45 | 0% | $45 |
| Maintenance Therapy - Periodontal | $192 | 0% | $192 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $303 | 0% | $303 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | 0% | $92 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | 0% | $60 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
| X-Ray - Complete Intraoral Series | $218 | 0% | $218 |
| X-Ray - Four Images, Bitewings | $75 | 0% | $75 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | 0% | $36 |
| X-Ray - Two Images, Bitewings | $54 | 0% | $54 |
| X-Ray - Whole Mouth from Outside Mouth | $149 | 0% | $149 |
