| Dental Cleaning - Adult | $160 | 0% | $160 |
| Dental Cleaning - Child | $113 | 0% | $113 |
| Dental Exam - Comprehensive | $153 | 0% | $153 |
| Dental Exam - Periodic, Established Patient | $55 | 0% | $55 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $194 | 0% | $194 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $506 | 0% | $506 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $232 | 0% | $232 |
| Dental Filling - White (Resin): One Surface, Posterior | $261 | 0% | $261 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $506 | 0% | $506 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $356 | 0% | $356 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $356 | 0% | $356 |
| Flouride - Topical Varnish Application | $64 | 0% | $64 |
| Maintenance Therapy - Periodontal | $211 | 0% | $211 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $40 | 0% | $40 |
| X-Ray - Complete Intraoral Series | $203 | 0% | $203 |
| X-Ray - Four Images, Bitewings | $113 | 0% | $113 |
| X-Ray - Intraoral, Periapical Radiographic Image | $41 | 0% | $41 |
| X-Ray - Whole Mouth from Outside Mouth | $203 | 0% | $203 |
