| Dental Cleaning - Adult | $127 | 0% | $127 |
| Dental Cleaning - Child | $92 | 0% | $92 |
| Dental Exam - Comprehensive | $120 | 0% | $120 |
| Dental Exam - Periodic, Established Patient | $62 | 0% | $62 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $201 | 0% | $201 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $281 | 0% | $281 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $253 | 0% | $253 |
| Dental Filling - White (Resin): One Surface, Anterior | $219 | 0% | $219 |
| Dental Filling - White (Resin): One Surface, Posterior | $237 | 0% | $237 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $399 | 0% | $399 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $266 | 0% | $266 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $322 | 0% | $322 |
| Flouride - Topical Varnish Application | $51 | 0% | $51 |
| Maintenance Therapy - Periodontal | $184 | 0% | $184 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $308 | 0% | $308 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $104 | 0% | $104 |
| Root Canal - Anterior Tooth | $1,200 | 0% | $1,200 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $67 | 0% | $67 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
| X-Ray - Complete Intraoral Series | $186 | 0% | $186 |
| X-Ray - Four Images, Bitewings | $90 | 0% | $90 |
| X-Ray - Intraoral, Periapical Radiographic Image | $45 | 0% | $45 |
| X-Ray - Two Images, Bitewings | $65 | 0% | $65 |
