| Dental Cleaning - Adult | $126 | 0% | $126 |
| Dental Cleaning - Child | $116 | 0% | $116 |
| Dental Exam - Comprehensive | $112 | 0% | $112 |
| Dental Exam - Periodic, Established Patient | $89 | 0% | $89 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $181 | 0% | $181 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $291 | 0% | $291 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $243 | 0% | $243 |
| Dental Filling - White (Resin): One Surface, Posterior | $191 | 0% | $191 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $299 | 0% | $299 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $211 | 0% | $211 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $253 | 0% | $253 |
| Fluoride - Topical Application | $85 | 0% | $85 |
| Maintenance Therapy - Periodontal | $183 | 0% | $183 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $107 | 0% | $107 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $89 | 0% | $89 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $63 | 0% | $63 |
| X-Ray - Complete Intraoral Series | $160 | 0% | $160 |
| X-Ray - Four Images, Bitewings | $95 | 0% | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $68 | 0% | $68 |
| X-Ray - Two Images, Bitewings | $84 | 0% | $84 |
| X-Ray - Whole Mouth from Outside Mouth | $154 | 0% | $154 |
