| Dental Cleaning - Adult | $102 | 0% | $102 |
| Dental Cleaning - Child | $102 | 0% | $102 |
| Dental Exam - Comprehensive | $88 | 0% | $88 |
| Dental Exam - Periodic, Established Patient | $48 | 0% | $48 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $142 | 0% | $142 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $216 | 0% | $216 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $176 | 0% | $176 |
| Dental Filling - White (Resin): One Surface, Anterior | $160 | 0% | $160 |
| Dental Filling - White (Resin): One Surface, Posterior | $184 | 0% | $184 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $334 | 0% | $334 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $196 | 0% | $196 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $257 | 0% | $257 |
| Flouride - Topical Varnish Application | $40 | 0% | $40 |
| Maintenance Therapy - Periodontal | $143 | 0% | $143 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $272 | 0% | $272 |
| Root Canal - Bicuspid Tooth | $951 | 0% | $951 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $111 | 0% | $111 |
| Tooth Extraction - Elevation and/or Forceps Removal | $177 | 0% | $177 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
| X-Ray - Complete Intraoral Series | $143 | 0% | $143 |
| X-Ray - Four Images, Bitewings | $69 | 0% | $69 |
| X-Ray - Intraoral, Periapical Radiographic Image | $33 | 0% | $33 |
| X-Ray - Two Images, Bitewings | $49 | 0% | $49 |
