| Dental Cleaning - Adult | $90 | 0% | $90 |
| Dental Cleaning - Child | $73 | 0% | $73 |
| Dental Exam - Comprehensive | $79 | 0% | $79 |
| Dental Exam - Periodic, Established Patient | $42 | 0% | $42 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $215 | 0% | $215 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $299 | 0% | $299 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $268 | 0% | $268 |
| Dental Filling - White (Resin): One Surface, Anterior | $215 | 0% | $215 |
| Dental Filling - White (Resin): One Surface, Posterior | $210 | 0% | $210 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $299 | 0% | $299 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $210 | 0% | $210 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $268 | 0% | $268 |
| Fluoride - Topical Application | $37 | 0% | $37 |
| Maintenance Therapy - Periodontal | $128 | 0% | $128 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $229 | 0% | $229 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $75 | 0% | $75 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $49 | 0% | $49 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Complete Intraoral Series | $126 | 0% | $126 |
| X-Ray - Four Images, Bitewings | $63 | 0% | $63 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
| X-Ray - Two Images, Bitewings | $43 | 0% | $43 |
