| Dental Cleaning - Adult | $141 | 0% | $141 |
| Dental Cleaning - Child | $119 | 0% | $119 |
| Dental Exam - Comprehensive | $137 | 0% | $137 |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $287 | 0% | $287 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $383 | 0% | $383 |
| Dental Filling - White (Resin): One Surface, Anterior | $278 | 0% | $278 |
| Dental Filling - White (Resin): One Surface, Posterior | $287 | 0% | $287 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $395 | 0% | $395 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $340 | 0% | $340 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $271 | 0% | $271 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | 0% | $38 |
| X-Ray - Complete Intraoral Series | $189 | 0% | $189 |
| X-Ray - Four Images, Bitewings | $92 | 0% | $92 |
| X-Ray - Intraoral, Periapical Radiographic Image | $43 | 0% | $43 |
| X-Ray - Two Images, Bitewings | $70 | 0% | $70 |
| X-Ray - Whole Mouth from Outside Mouth | $168 | 0% | $168 |
