| Dental Cleaning - Adult | $122 | 0% | $122 |
| Dental Cleaning - Child | $90 | 0% | $90 |
| Dental Exam - Comprehensive | $104 | 0% | $104 |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $171 | 0% | $171 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $266 | 0% | $266 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $223 | 0% | $223 |
| Dental Filling - White (Resin): One Surface, Anterior | $204 | 0% | $204 |
| Dental Filling - White (Resin): One Surface, Posterior | $208 | 0% | $208 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $329 | 0% | $329 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $318 | 0% | $318 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $271 | 0% | $271 |
| Flouride - Topical Varnish Application | $53 | 0% | $53 |
| Fluoride - Topical Application | $65 | 0% | $65 |
| Maintenance Therapy - Periodontal | $171 | 0% | $171 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $293 | 0% | $293 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $102 | 0% | $102 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $53 | 0% | $53 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | 0% | $33 |
| X-Ray - Complete Intraoral Series | $205 | 0% | $205 |
| X-Ray - Four Images, Bitewings | $75 | 0% | $75 |
| X-Ray - Intraoral, Periapical Radiographic Image | $44 | 0% | $44 |
| X-Ray - Two Images, Bitewings | $53 | 0% | $53 |
| X-Ray - Whole Mouth from Outside Mouth | $135 | 0% | $135 |
