| Dental Cleaning - Adult | $120 | 0% | $120 |
| Dental Exam - Comprehensive | $109 | 0% | $109 |
| Dental Exam - Periodic, Established Patient | $64 | 0% | $64 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $221 | 0% | $221 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $336 | 0% | $336 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $289 | 0% | $289 |
| Dental Filling - White (Resin): One Surface, Posterior | $226 | 0% | $226 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $336 | 0% | $336 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $289 | 0% | $289 |
| Maintenance Therapy - Periodontal | $165 | 0% | $165 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $303 | 0% | $303 |
| Root Canal - Molar | $1,439 | 0% | $1,439 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $39 | 0% | $39 |
| X-Ray - Complete Intraoral Series | $235 | 0% | $235 |
| X-Ray - Four Images, Bitewings | $92 | 0% | $92 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
| X-Ray - Whole Mouth from Outside Mouth | $159 | 0% | $159 |
