| Dental Cleaning - Adult | $110 | 0% | $110 |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $185 | 0% | $185 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $227 | 0% | $227 |
| Dental Filling - White (Resin): One Surface, Anterior | $208 | 0% | $208 |
| Dental Filling - White (Resin): One Surface, Posterior | $202 | 0% | $202 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $289 | 0% | $289 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $205 | 0% | $205 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $205 | 0% | $205 |
| Flouride - Topical Varnish Application | $42 | 0% | $42 |
| Fluoride - Topical Application | $71 | 0% | $71 |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | 0% | $184 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Complete Intraoral Series | $197 | 0% | $197 |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
