| Dental Cleaning - Adult | $104 | 0% | $104 |
| Dental Cleaning - Child | $84 | 0% | $84 |
| Dental Exam - Comprehensive | $129 | 0% | $129 |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $144 | 0% | $144 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $221 | 0% | $221 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $181 | 0% | $181 |
| Dental Filling - White (Resin): One Surface, Anterior | $164 | 0% | $164 |
| Dental Filling - White (Resin): One Surface, Posterior | $188 | 0% | $188 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $201 | 0% | $201 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $261 | 0% | $261 |
| Fluoride - Topical Application | $43 | 0% | $43 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $182 | 0% | $182 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $63 | 0% | $63 |
| X-Ray - Intraoral, Periapical Radiographic Image | $33 | 0% | $33 |
