| Dental Cleaning - Adult | $121 | 0% | $121 |
| Dental Cleaning - Child | $92 | 0% | $92 |
| Dental Exam - Comprehensive | $92 | 0% | $92 |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $196 | 0% | $196 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $284 | 0% | $284 |
| Dental Filling - White (Resin): One Surface, Anterior | $168 | 0% | $168 |
| Dental Filling - White (Resin): One Surface, Posterior | $196 | 0% | $196 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $351 | 0% | $351 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $215 | 0% | $215 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $284 | 0% | $284 |
| Flouride - Topical Varnish Application | $44 | 0% | $44 |
| Fluoride - Topical Application | $44 | 0% | $44 |
| Maintenance Therapy - Periodontal | $182 | 0% | $182 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $320 | 0% | $320 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $93 | 0% | $93 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
| X-Ray - Complete Intraoral Series | $187 | 0% | $187 |
| X-Ray - Four Images, Bitewings | $77 | 0% | $77 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
| X-Ray - Two Images, Bitewings | $51 | 0% | $51 |
