| Dental Cleaning - Adult | $100 | 0% | $100 |
| Dental Cleaning - Child | $68 | 0% | $68 |
| Dental Exam - Comprehensive | $89 | 0% | $89 |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $184 | 0% | $184 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $315 | 0% | $315 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $242 | 0% | $242 |
| Dental Filling - White (Resin): One Surface, Anterior | $158 | 0% | $158 |
| Dental Filling - White (Resin): One Surface, Posterior | $181 | 0% | $181 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $284 | 0% | $284 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $189 | 0% | $189 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $242 | 0% | $242 |
| Flouride - Topical Varnish Application | $43 | 0% | $43 |
| Fluoride - Topical Application | $42 | 0% | $42 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $263 | 0% | $263 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | 0% | $105 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $47 | 0% | $47 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $21 | 0% | $21 |
| X-Ray - Complete Intraoral Series | $137 | 0% | $137 |
| X-Ray - Four Images, Bitewings | $68 | 0% | $68 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
| X-Ray - Two Images, Bitewings | $68 | 0% | $68 |
| X-Ray - Whole Mouth from Outside Mouth | $126 | 0% | $126 |
