| Dental Cleaning - Adult | $110 | 0% | $110 |
| Dental Cleaning - Child | $120 | 0% | $120 |
| Dental Exam - Comprehensive | $120 | 0% | $120 |
| Dental Exam - Periodic, Established Patient | $50 | 0% | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $200 | 0% | $200 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $340 | 0% | $340 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | 0% | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $167 | 0% | $167 |
| Dental Filling - White (Resin): One Surface, Posterior | $191 | 0% | $191 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $340 | 0% | $340 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $205 | 0% | $205 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $293 | 0% | $293 |
| Flouride - Topical Varnish Application | $53 | 0% | $53 |
| Fluoride - Topical Application | $53 | 0% | $53 |
| Maintenance Therapy - Periodontal | $154 | 0% | $154 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $280 | 0% | $280 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
| Root Canal - Anterior Tooth | $1,087 | 0% | $1,087 |
| Root Canal - Bicuspid Tooth | $1,541 | 0% | $1,541 |
| Root Canal - Molar | $1,219 | 0% | $1,219 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | 0% | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $260 | 0% | $260 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $22 | 0% | $22 |
| X-Ray - Complete Intraoral Series | $148 | 0% | $148 |
| X-Ray - Four Images, Bitewings | $95 | 0% | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $76 | 0% | $76 |
| X-Ray - Whole Mouth from Outside Mouth | $131 | 0% | $131 |
