| Dental Cleaning - Adult | $126 | 0% | $126 |
| Dental Cleaning - Child | $112 | 0% | $112 |
| Dental Exam - Comprehensive | $116 | 0% | $116 |
| Dental Exam - Periodic, Established Patient | $68 | 0% | $68 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $399 | 0% | $399 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $452 | 0% | $452 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $242 | 0% | $242 |
| Dental Filling - White (Resin): One Surface, Anterior | $315 | 0% | $315 |
| Dental Filling - White (Resin): One Surface, Posterior | $399 | 0% | $399 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $578 | 0% | $578 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $389 | 0% | $389 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $483 | 0% | $483 |
| Fluoride - Topical Application | $63 | 0% | $63 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $630 | 0% | $630 |
| Tooth Extraction - Elevation and/or Forceps Removal | $276 | 0% | $276 |
| X-Ray - Two Images, Bitewings | $75 | 0% | $75 |
