| Dental Cleaning - Adult | $100 | 0% | $100 |
| Dental Cleaning - Child | $74 | 0% | $74 |
| Dental Exam - Comprehensive | $89 | 0% | $89 |
| Dental Exam - Periodic, Established Patient | $42 | 0% | $42 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $126 | 0% | $126 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $210 | 0% | $210 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $168 | 0% | $168 |
| Dental Filling - White (Resin): One Surface, Anterior | $158 | 0% | $158 |
| Dental Filling - White (Resin): One Surface, Posterior | $179 | 0% | $179 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $294 | 0% | $294 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $200 | 0% | $200 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $236 | 0% | $236 |
| Fluoride - Topical Application | $37 | 0% | $37 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $275 | 0% | $275 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | 0% | $95 |
| Root Canal - Anterior Tooth | $735 | 0% | $735 |
| Root Canal - Bicuspid Tooth | $840 | 0% | $840 |
| Root Canal - Molar | $1,155 | 0% | $1,155 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $183 | 0% | $183 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $7 | 0% | $7 |
| X-Ray - Complete Intraoral Series | $146 | 0% | $146 |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
