| Dental Cleaning - Adult | $128 | 0% | $128 |
| Dental Cleaning - Child | $102 | 0% | $102 |
| Dental Exam - Comprehensive | $170 | 0% | $170 |
| Dental Exam - Periodic, Established Patient | $61 | 0% | $61 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $224 | 0% | $224 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $387 | 0% | $387 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $276 | 0% | $276 |
| Dental Filling - White (Resin): One Surface, Anterior | $229 | 0% | $229 |
| Dental Filling - White (Resin): One Surface, Posterior | $224 | 0% | $224 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $387 | 0% | $387 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $245 | 0% | $245 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $287 | 0% | $287 |
| Flouride - Topical Varnish Application | $49 | 0% | $49 |
| Fluoride - Topical Application | $49 | 0% | $49 |
| Maintenance Therapy - Periodontal | $186 | 0% | $186 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $297 | 0% | $297 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | 0% | $95 |
| Root Canal - Anterior Tooth | $968 | 0% | $968 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | 0% | $68 |
| X-Ray - Complete Intraoral Series | $203 | 0% | $203 |
| X-Ray - Four Images, Bitewings | $87 | 0% | $87 |
| X-Ray - Intraoral, Periapical Radiographic Image | $49 | 0% | $49 |
| X-Ray - Two Images, Bitewings | $61 | 0% | $61 |
| X-Ray - Whole Mouth from Outside Mouth | $184 | 0% | $184 |
