| Dental Cleaning - Adult | $125 | 0% | $125 |
| Dental Cleaning - Child | $92 | 0% | $92 |
| Dental Exam - Comprehensive | $113 | 0% | $113 |
| Dental Exam - Periodic, Established Patient | $67 | 0% | $67 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $236 | 0% | $236 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $295 | 0% | $295 |
| Dental Filling - White (Resin): One Surface, Anterior | $219 | 0% | $219 |
| Dental Filling - White (Resin): One Surface, Posterior | $230 | 0% | $230 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $256 | 0% | $256 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $295 | 0% | $295 |
| Flouride - Topical Varnish Application | $45 | 0% | $45 |
| Fluoride - Topical Application | $51 | 0% | $51 |
| Maintenance Therapy - Periodontal | $313 | 0% | $313 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $331 | 0% | $331 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $109 | 0% | $109 |
| Root Canal - Molar | $1,575 | 0% | $1,575 |
| X-Ray - Complete Intraoral Series | $270 | 0% | $270 |
| X-Ray - Four Images, Bitewings | $91 | 0% | $91 |
| X-Ray - Intraoral, Periapical Radiographic Image | $68 | 0% | $68 |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
| X-Ray - Whole Mouth from Outside Mouth | $180 | 0% | $180 |
