| Dental Cleaning - Adult | $104 | 0% | $104 |
| Dental Cleaning - Child | $86 | 0% | $86 |
| Dental Exam - Comprehensive | $90 | 0% | $90 |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $179 | 0% | $179 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $305 | 0% | $305 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $252 | 0% | $252 |
| Dental Filling - White (Resin): One Surface, Anterior | $162 | 0% | $162 |
| Dental Filling - White (Resin): One Surface, Posterior | $179 | 0% | $179 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $305 | 0% | $305 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $198 | 0% | $198 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $252 | 0% | $252 |
| Fluoride - Topical Application | $43 | 0% | $43 |
| Maintenance Therapy - Periodontal | $150 | 0% | $150 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $276 | 0% | $276 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | 0% | $88 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
| X-Ray - Complete Intraoral Series | $145 | 0% | $145 |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
