| Dental Cleaning - Adult | $107 | 0% | $107 |
| Dental Cleaning - Child | $86 | 0% | $86 |
| Dental Exam - Comprehensive | $126 | 0% | $126 |
| Dental Exam - Periodic, Established Patient | $50 | 0% | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $205 | 0% | $205 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $357 | 0% | $357 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $281 | 0% | $281 |
| Dental Filling - White (Resin): One Surface, Anterior | $194 | 0% | $194 |
| Dental Filling - White (Resin): One Surface, Posterior | $205 | 0% | $205 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $357 | 0% | $357 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $239 | 0% | $239 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $281 | 0% | $281 |
| Fluoride - Topical Application | $43 | 0% | $43 |
| Maintenance Therapy - Periodontal | $160 | 0% | $160 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $320 | 0% | $320 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
| X-Ray - Complete Intraoral Series | $148 | 0% | $148 |
| X-Ray - Four Images, Bitewings | $72 | 0% | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $51 | 0% | $51 |
