| Dental Cleaning - Adult | $100 | 0% | $100 |
| Dental Cleaning - Child | $74 | 0% | $74 |
| Dental Exam - Comprehensive | $98 | 0% | $98 |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $207 | 0% | $207 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | 0% | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | 0% | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $187 | 0% | $187 |
| Dental Filling - White (Resin): One Surface, Posterior | $215 | 0% | $215 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $347 | 0% | $347 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $236 | 0% | $236 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
| Flouride - Topical Varnish Application | $30 | 0% | $30 |
| Maintenance Therapy - Periodontal | $140 | 0% | $140 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $280 | 0% | $280 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | 0% | $88 |
| Root Canal - Bicuspid Tooth | $979 | 0% | $979 |
| Root Canal - Molar | $1,219 | 0% | $1,219 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $57 | 0% | $57 |
| Tooth Extraction - Elevation and/or Forceps Removal | $231 | 0% | $231 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
| X-Ray - Complete Intraoral Series | $177 | 0% | $177 |
| X-Ray - Four Images, Bitewings | $72 | 0% | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $56 | 0% | $56 |
| X-Ray - Whole Mouth from Outside Mouth | $137 | 0% | $137 |
