| Dental Cleaning - Adult | $130 | 0% | $130 |
| Dental Cleaning - Child | $89 | 0% | $89 |
| Dental Exam - Comprehensive | $100 | 0% | $100 |
| Dental Exam - Periodic, Established Patient | $71 | 0% | $71 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | 0% | $189 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | 0% | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $192 | 0% | $192 |
| Dental Filling - White (Resin): One Surface, Posterior | $208 | 0% | $208 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $320 | 0% | $320 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $275 | 0% | $275 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
| Flouride - Topical Varnish Application | $51 | 0% | $51 |
| Fluoride - Topical Application | $71 | 0% | $71 |
| Maintenance Therapy - Periodontal | $166 | 0% | $166 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $161 | 0% | $161 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $284 | 0% | $284 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | 0% | $71 |
| Tooth Extraction - Elevation and/or Forceps Removal | $236 | 0% | $236 |
| X-Ray - Complete Intraoral Series | $168 | 0% | $168 |
| X-Ray - Four Images, Bitewings | $92 | 0% | $92 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
| X-Ray - Two Images, Bitewings | $78 | 0% | $78 |
