| Dental Cleaning - Adult | $122 | 0% | $122 |
| Dental Cleaning - Child | $88 | 0% | $88 |
| Dental Exam - Comprehensive | $98 | 0% | $98 |
| Dental Exam - Periodic, Established Patient | $51 | 0% | $51 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $233 | 0% | $233 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $392 | 0% | $392 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $306 | 0% | $306 |
| Dental Filling - White (Resin): One Surface, Anterior | $178 | 0% | $178 |
| Dental Filling - White (Resin): One Surface, Posterior | $240 | 0% | $240 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $403 | 0% | $403 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $226 | 0% | $226 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $306 | 0% | $306 |
| Flouride - Topical Varnish Application | $50 | 0% | $50 |
| Maintenance Therapy - Periodontal | $160 | 0% | $160 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $309 | 0% | $309 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $98 | 0% | $98 |
| Root Canal - Bicuspid Tooth | $1,130 | 0% | $1,130 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $67 | 0% | $67 |
| Tooth Extraction - Elevation and/or Forceps Removal | $210 | 0% | $210 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
| X-Ray - Complete Intraoral Series | $169 | 0% | $169 |
| X-Ray - Four Images, Bitewings | $80 | 0% | $80 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | 0% | $36 |
| X-Ray - Two Images, Bitewings | $55 | 0% | $55 |
| X-Ray - Whole Mouth from Outside Mouth | $139 | 0% | $139 |
