| Dental Cleaning - Adult | $131 | 0% | $131 |
| Dental Cleaning - Child | $104 | 0% | $104 |
| Dental Exam - Comprehensive | $105 | 0% | $105 |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $305 | 0% | $305 |
| Dental Filling - White (Resin): One Surface, Posterior | $252 | 0% | $252 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $425 | 0% | $425 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $278 | 0% | $278 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $305 | 0% | $305 |
| Flouride - Topical Varnish Application | $57 | 0% | $57 |
| Maintenance Therapy - Periodontal | $198 | 0% | $198 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $319 | 0% | $319 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | 0% | $100 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $77 | 0% | $77 |
| X-Ray - Complete Intraoral Series | $161 | 0% | $161 |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | 0% | $36 |
| X-Ray - Two Images, Bitewings | $66 | 0% | $66 |
| X-Ray - Whole Mouth from Outside Mouth | $142 | 0% | $142 |
