| Dental Cleaning - Adult | $128 | 0% | $128 |
| Dental Cleaning - Child | $104 | 0% | $104 |
| Dental Exam - Comprehensive | $118 | 0% | $118 |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $219 | 0% | $219 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $358 | 0% | $358 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $300 | 0% | $300 |
| Dental Filling - White (Resin): One Surface, Anterior | $205 | 0% | $205 |
| Dental Filling - White (Resin): One Surface, Posterior | $219 | 0% | $219 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $358 | 0% | $358 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $246 | 0% | $246 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $300 | 0% | $300 |
| Flouride - Topical Varnish Application | $53 | 0% | $53 |
| Maintenance Therapy - Periodontal | $184 | 0% | $184 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $320 | 0% | $320 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $110 | 0% | $110 |
| Root Canal - Anterior Tooth | $1,103 | 0% | $1,103 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $79 | 0% | $79 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $39 | 0% | $39 |
| X-Ray - Complete Intraoral Series | $179 | 0% | $179 |
| X-Ray - Four Images, Bitewings | $95 | 0% | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
| X-Ray - Two Images, Bitewings | $71 | 0% | $71 |
| X-Ray - Whole Mouth from Outside Mouth | $179 | 0% | $179 |
