| Dental Cleaning - Adult | $116 | 0% | $116 |
| Dental Cleaning - Child | $116 | 0% | $116 |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $200 | 0% | $200 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $352 | 0% | $352 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | 0% | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $357 | 0% | $357 |
| Dental Filling - White (Resin): One Surface, Posterior | $200 | 0% | $200 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $352 | 0% | $352 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $210 | 0% | $210 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
| Flouride - Topical Varnish Application | $95 | 0% | $95 |
| Fluoride - Topical Application | $86 | 0% | $86 |
| Maintenance Therapy - Periodontal | $149 | 0% | $149 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $272 | 0% | $272 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | 0% | $95 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $92 | 0% | $92 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Complete Intraoral Series | $158 | 0% | $158 |
| X-Ray - Four Images, Bitewings | $79 | 0% | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
| X-Ray - Two Images, Bitewings | $79 | 0% | $79 |
