| Dental Cleaning - Adult | $119 | 0% | $119 |
| Dental Cleaning - Child | $87 | 0% | $87 |
| Dental Exam - Comprehensive | $112 | 0% | $112 |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $223 | 0% | $223 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $356 | 0% | $356 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $287 | 0% | $287 |
| Dental Filling - White (Resin): One Surface, Anterior | $207 | 0% | $207 |
| Dental Filling - White (Resin): One Surface, Posterior | $223 | 0% | $223 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $356 | 0% | $356 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $254 | 0% | $254 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $287 | 0% | $287 |
| Flouride - Topical Varnish Application | $43 | 0% | $43 |
| Maintenance Therapy - Periodontal | $168 | 0% | $168 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $318 | 0% | $318 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $102 | 0% | $102 |
| Root Canal - Bicuspid Tooth | $1,092 | 0% | $1,092 |
| Tooth Extraction - Elevation and/or Forceps Removal | $221 | 0% | $221 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Complete Intraoral Series | $169 | 0% | $169 |
| X-Ray - Four Images, Bitewings | $83 | 0% | $83 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
| X-Ray - Two Images, Bitewings | $59 | 0% | $59 |
| X-Ray - Whole Mouth from Outside Mouth | $169 | 0% | $169 |
