| Dental Cleaning - Adult | $116 | 0% | $116 |
| Dental Cleaning - Child | $89 | 0% | $89 |
| Dental Exam - Comprehensive | $110 | 0% | $110 |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $165 | 0% | $165 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $334 | 0% | $334 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $158 | 0% | $158 |
| Dental Filling - White (Resin): One Surface, Posterior | $214 | 0% | $214 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $424 | 0% | $424 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $200 | 0% | $200 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $242 | 0% | $242 |
| Fluoride - Topical Application | $63 | 0% | $63 |
| Maintenance Therapy - Periodontal | $173 | 0% | $173 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $289 | 0% | $289 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | 0% | $105 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | 0% | $74 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | 0% | $33 |
| X-Ray - Complete Intraoral Series | $163 | 0% | $163 |
| X-Ray - Four Images, Bitewings | $89 | 0% | $89 |
| X-Ray - Intraoral, Periapical Radiographic Image | $44 | 0% | $44 |
| X-Ray - Two Images, Bitewings | $74 | 0% | $74 |
