| Dental Cleaning - Adult | $110 | 0% | $110 |
| Dental Cleaning - Child | $110 | 0% | $110 |
| Dental Exam - Comprehensive | $104 | 0% | $104 |
| Dental Exam - Periodic, Established Patient | $57 | 0% | $57 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $201 | 0% | $201 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $344 | 0% | $344 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | 0% | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $179 | 0% | $179 |
| Dental Filling - White (Resin): One Surface, Posterior | $201 | 0% | $201 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $344 | 0% | $344 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $225 | 0% | $225 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
| Fluoride - Topical Application | $69 | 0% | $69 |
| Maintenance Therapy - Periodontal | $154 | 0% | $154 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $281 | 0% | $281 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | 0% | $92 |
| Root Canal - Anterior Tooth | $935 | 0% | $935 |
| Root Canal - Bicuspid Tooth | $1,113 | 0% | $1,113 |
| Root Canal - Molar | $1,575 | 0% | $1,575 |
| Tooth Extraction - Elevation and/or Forceps Removal | $221 | 0% | $221 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | 0% | $30 |
| X-Ray - Complete Intraoral Series | $152 | 0% | $152 |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
