| Dental Cleaning - Adult | $112 | 0% | $112 |
| Dental Cleaning - Child | $87 | 0% | $87 |
| Dental Exam - Comprehensive | $111 | 0% | $111 |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $225 | 0% | $225 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $282 | 0% | $282 |
| Dental Filling - White (Resin): One Surface, Anterior | $205 | 0% | $205 |
| Dental Filling - White (Resin): One Surface, Posterior | $225 | 0% | $225 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $352 | 0% | $352 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $259 | 0% | $259 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $282 | 0% | $282 |
| Flouride - Topical Varnish Application | $40 | 0% | $40 |
| Maintenance Therapy - Periodontal | $139 | 0% | $139 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $292 | 0% | $292 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $96 | 0% | $96 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $67 | 0% | $67 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Complete Intraoral Series | $164 | 0% | $164 |
| X-Ray - Four Images, Bitewings | $83 | 0% | $83 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
| X-Ray - Two Images, Bitewings | $56 | 0% | $56 |
| X-Ray - Whole Mouth from Outside Mouth | $263 | 0% | $263 |
