| Dental Cleaning - Adult | $120 | 0% | $120 |
| Dental Cleaning - Child | $176 | 0% | $176 |
| Dental Exam - Comprehensive | $121 | 0% | $121 |
| Dental Exam - Periodic, Established Patient | $71 | 0% | $71 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $258 | 0% | $258 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $404 | 0% | $404 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $280 | 0% | $280 |
| Dental Filling - White (Resin): One Surface, Anterior | $236 | 0% | $236 |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | 0% | $221 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $685 | 0% | $685 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $251 | 0% | $251 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $280 | 0% | $280 |
| Fluoride - Topical Application | $49 | 0% | $49 |
| Maintenance Therapy - Periodontal | $179 | 0% | $179 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $309 | 0% | $309 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $99 | 0% | $99 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | 0% | $74 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Complete Intraoral Series | $179 | 0% | $179 |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
| X-Ray - Whole Mouth from Outside Mouth | $168 | 0% | $168 |
