| Dental Cleaning - Adult | $90 | 0% | $90 |
| Dental Cleaning - Child | $63 | 0% | $63 |
| Dental Exam - Comprehensive | $91 | 0% | $91 |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $242 | 0% | $242 |
| Dental Filling - White (Resin): One Surface, Posterior | $200 | 0% | $200 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $284 | 0% | $284 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $202 | 0% | $202 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $242 | 0% | $242 |
| Flouride - Topical Varnish Application | $35 | 0% | $35 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $236 | 0% | $236 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $86 | 0% | $86 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $50 | 0% | $50 |
| X-Ray - Complete Intraoral Series | $132 | 0% | $132 |
| X-Ray - Four Images, Bitewings | $64 | 0% | $64 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $48 | 0% | $48 |
