| Dental Cleaning - Adult | $100 | 0% | $100 |
| Dental Cleaning - Child | $74 | 0% | $74 |
| Dental Exam - Comprehensive | $91 | 0% | $91 |
| Dental Exam - Periodic, Established Patient | $57 | 0% | $57 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $191 | 0% | $191 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $246 | 0% | $246 |
| Dental Filling - White (Resin): One Surface, Anterior | $174 | 0% | $174 |
| Dental Filling - White (Resin): One Surface, Posterior | $191 | 0% | $191 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $269 | 0% | $269 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $246 | 0% | $246 |
| Flouride - Topical Varnish Application | $46 | 0% | $46 |
| Maintenance Therapy - Periodontal | $131 | 0% | $131 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $263 | 0% | $263 |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | 0% | $184 |
| X-Ray - Complete Intraoral Series | $174 | 0% | $174 |
| X-Ray - Four Images, Bitewings | $74 | 0% | $74 |
| X-Ray - Intraoral, Periapical Radiographic Image | $26 | 0% | $26 |
| X-Ray - Whole Mouth from Outside Mouth | $126 | 0% | $126 |
