| Dental Cleaning - Adult | $139 | 0% | $139 |
| Dental Cleaning - Child | $113 | 0% | $113 |
| Dental Exam - Comprehensive | $158 | 0% | $158 |
| Dental Exam - Periodic, Established Patient | $72 | 0% | $72 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $236 | 0% | $236 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $373 | 0% | $373 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $315 | 0% | $315 |
| Dental Filling - White (Resin): One Surface, Anterior | $242 | 0% | $242 |
| Dental Filling - White (Resin): One Surface, Posterior | $239 | 0% | $239 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $378 | 0% | $378 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $278 | 0% | $278 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $315 | 0% | $315 |
| Fluoride - Topical Application | $55 | 0% | $55 |
| Maintenance Therapy - Periodontal | $205 | 0% | $205 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $347 | 0% | $347 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $126 | 0% | $126 |
| Root Canal - Anterior Tooth | $1,076 | 0% | $1,076 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $315 | 0% | $315 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
| X-Ray - Complete Intraoral Series | $184 | 0% | $184 |
| X-Ray - Four Images, Bitewings | $95 | 0% | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $44 | 0% | $44 |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
| X-Ray - Whole Mouth from Outside Mouth | $184 | 0% | $184 |
