| Dental Cleaning - Adult | $119 | 0% | $119 |
| Dental Cleaning - Child | $93 | 0% | $93 |
| Dental Exam - Comprehensive | $112 | 0% | $112 |
| Dental Exam - Periodic, Established Patient | $70 | 0% | $70 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $240 | 0% | $240 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $369 | 0% | $369 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $301 | 0% | $301 |
| Dental Filling - White (Resin): One Surface, Anterior | $230 | 0% | $230 |
| Dental Filling - White (Resin): One Surface, Posterior | $238 | 0% | $238 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $375 | 0% | $375 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $277 | 0% | $277 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $301 | 0% | $301 |
| Flouride - Topical Varnish Application | $56 | 0% | $56 |
| Fluoride - Topical Application | $54 | 0% | $54 |
| Maintenance Therapy - Periodontal | $175 | 0% | $175 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $343 | 0% | $343 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $110 | 0% | $110 |
| Root Canal - Bicuspid Tooth | $1,099 | 0% | $1,099 |
| Root Canal - Molar | $1,309 | 0% | $1,309 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $75 | 0% | $75 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
| X-Ray - Complete Intraoral Series | $171 | 0% | $171 |
| X-Ray - Four Images, Bitewings | $87 | 0% | $87 |
| X-Ray - Intraoral, Periapical Radiographic Image | $43 | 0% | $43 |
| X-Ray - Two Images, Bitewings | $60 | 0% | $60 |
| X-Ray - Whole Mouth from Outside Mouth | $154 | 0% | $154 |
