| Dental Cleaning - Adult | $113 | 0% | $113 |
| Dental Cleaning - Child | $95 | 0% | $95 |
| Dental Exam - Comprehensive | $95 | 0% | $95 |
| Dental Exam - Periodic, Established Patient | $51 | 0% | $51 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $203 | 0% | $203 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $393 | 0% | $393 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $284 | 0% | $284 |
| Dental Filling - White (Resin): One Surface, Anterior | $173 | 0% | $173 |
| Dental Filling - White (Resin): One Surface, Posterior | $203 | 0% | $203 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $365 | 0% | $365 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $212 | 0% | $212 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $284 | 0% | $284 |
| Flouride - Topical Varnish Application | $44 | 0% | $44 |
| Maintenance Therapy - Periodontal | $159 | 0% | $159 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $308 | 0% | $308 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | 0% | $92 |
| 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 | $156 | 0% | $156 |
| X-Ray - Four Images, Bitewings | $75 | 0% | $75 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | 0% | $36 |
| X-Ray - Two Images, Bitewings | $53 | 0% | $53 |
