| Dental Cleaning - Adult | $100 | 0% | $100 |
| Dental Cleaning - Child | $79 | 0% | $79 |
| Dental Exam - Comprehensive | $92 | 0% | $92 |
| Dental Exam - Periodic, Established Patient | $42 | 0% | $42 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $184 | 0% | $184 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $334 | 0% | $334 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $257 | 0% | $257 |
| Dental Filling - White (Resin): One Surface, Anterior | $160 | 0% | $160 |
| Dental Filling - White (Resin): One Surface, Posterior | $184 | 0% | $184 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $334 | 0% | $334 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $196 | 0% | $196 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $257 | 0% | $257 |
| Fluoride - Topical Application | $42 | 0% | $42 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $56 | 0% | $56 |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | 0% | $184 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
| X-Ray - Complete Intraoral Series | $142 | 0% | $142 |
| X-Ray - Four Images, Bitewings | $68 | 0% | $68 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
| X-Ray - Two Images, Bitewings | $47 | 0% | $47 |
