| Dental Cleaning - Adult | $101 | 0% | $101 |
| Dental Cleaning - Child | $72 | 0% | $72 |
| Dental Exam - Comprehensive | $77 | 0% | $77 |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $186 | 0% | $186 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | 0% | $326 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | 0% | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $212 | 0% | $212 |
| Dental Filling - White (Resin): One Surface, Posterior | $186 | 0% | $186 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $391 | 0% | $391 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $198 | 0% | $198 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $259 | 0% | $259 |
| Flouride - Topical Varnish Application | $43 | 0% | $43 |
| Fluoride - Topical Application | $42 | 0% | $42 |
| Maintenance Therapy - Periodontal | $128 | 0% | $128 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $244 | 0% | $244 |
| Tooth Extraction - Elevation and/or Forceps Removal | $291 | 0% | $291 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $17 | 0% | $17 |
| X-Ray - Complete Intraoral Series | $139 | 0% | $139 |
| X-Ray - Four Images, Bitewings | $95 | 0% | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $27 | 0% | $27 |
| X-Ray - Two Images, Bitewings | $43 | 0% | $43 |
