| Dental Cleaning - Adult | $110 | 0% | $110 |
| Dental Cleaning - Child | $83 | 0% | $83 |
| Dental Exam - Comprehensive | $101 | 0% | $101 |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $198 | 0% | $198 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | 0% | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | 0% | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $188 | 0% | $188 |
| Dental Filling - White (Resin): One Surface, Posterior | $198 | 0% | $198 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | 0% | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $219 | 0% | $219 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $265 | 0% | $265 |
| Fluoride - Topical Application | $43 | 0% | $43 |
| Maintenance Therapy - Periodontal | $154 | 0% | $154 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $272 | 0% | $272 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | 0% | $92 |
| Root Canal - Anterior Tooth | $866 | 0% | $866 |
| Root Canal - Bicuspid Tooth | $998 | 0% | $998 |
| Root Canal - Molar | $1,208 | 0% | $1,208 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | 0% | $61 |
| Tooth Extraction - Elevation and/or Forceps Removal | $194 | 0% | $194 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
| X-Ray - Complete Intraoral Series | $156 | 0% | $156 |
| X-Ray - Four Images, Bitewings | $74 | 0% | $74 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $53 | 0% | $53 |
| X-Ray - Whole Mouth from Outside Mouth | $156 | 0% | $156 |
