| Dental Cleaning - Adult | $122 | 0% | $122 |
| Dental Cleaning - Child | $90 | 0% | $90 |
| Dental Exam - Comprehensive | $182 | 0% | $182 |
| Dental Exam - Periodic, Established Patient | $57 | 0% | $57 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $188 | 0% | $188 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $236 | 0% | $236 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $213 | 0% | $213 |
| Dental Filling - White (Resin): One Surface, Anterior | $203 | 0% | $203 |
| Dental Filling - White (Resin): One Surface, Posterior | $213 | 0% | $213 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $347 | 0% | $347 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $239 | 0% | $239 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $278 | 0% | $278 |
| Flouride - Topical Varnish Application | $40 | 0% | $40 |
| Fluoride - Topical Application | $45 | 0% | $45 |
| Maintenance Therapy - Periodontal | $200 | 0% | $200 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $293 | 0% | $293 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $123 | 0% | $123 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $62 | 0% | $62 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
| X-Ray - Complete Intraoral Series | $189 | 0% | $189 |
| X-Ray - Four Images, Bitewings | $81 | 0% | $81 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $62 | 0% | $62 |
| X-Ray - Whole Mouth from Outside Mouth | $175 | 0% | $175 |
