| Dental Cleaning - Adult | $108 | 0% | $108 |
| Dental Cleaning - Child | $87 | 0% | $87 |
| Dental Exam - Comprehensive | $92 | 0% | $92 |
| Dental Exam - Periodic, Established Patient | $51 | 0% | $51 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $191 | 0% | $191 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $344 | 0% | $344 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | 0% | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | 0% | $184 |
| Dental Filling - White (Resin): One Surface, Posterior | $191 | 0% | $191 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $344 | 0% | $344 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $210 | 0% | $210 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $265 | 0% | $265 |
| Flouride - Topical Varnish Application | $44 | 0% | $44 |
| Fluoride - Topical Application | $43 | 0% | $43 |
| Maintenance Therapy - Periodontal | $155 | 0% | $155 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $284 | 0% | $284 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | 0% | $92 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | 0% | $60 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Complete Intraoral Series | $150 | 0% | $150 |
| X-Ray - Four Images, Bitewings | $74 | 0% | $74 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
| X-Ray - Two Images, Bitewings | $54 | 0% | $54 |
