| Dental Cleaning - Adult | $142 | 0% | $142 |
| Dental Cleaning - Child | $99 | 0% | $99 |
| Dental Exam - Comprehensive | $158 | 0% | $158 |
| Dental Exam - Periodic, Established Patient | $66 | 0% | $66 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $237 | 0% | $237 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $411 | 0% | $411 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $314 | 0% | $314 |
| Dental Filling - White (Resin): One Surface, Anterior | $280 | 0% | $280 |
| Dental Filling - White (Resin): One Surface, Posterior | $292 | 0% | $292 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $383 | 0% | $383 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $431 | 0% | $431 |
| Flouride - Topical Varnish Application | $64 | 0% | $64 |
| Maintenance Therapy - Periodontal | $171 | 0% | $171 |
| Root Canal - Bicuspid Tooth | $1,265 | 0% | $1,265 |
| Root Canal - Molar | $1,565 | 0% | $1,565 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $91 | 0% | $91 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $46 | 0% | $46 |
| X-Ray - Complete Intraoral Series | $214 | 0% | $214 |
| X-Ray - Four Images, Bitewings | $108 | 0% | $108 |
| X-Ray - Intraoral, Periapical Radiographic Image | $51 | 0% | $51 |
| X-Ray - Two Images, Bitewings | $78 | 0% | $78 |
| X-Ray - Whole Mouth from Outside Mouth | $218 | 0% | $218 |
