| Dental Cleaning - Adult | $120 | 0% | $120 |
| Dental Cleaning - Child | $176 | 0% | $176 |
| Dental Exam - Comprehensive | $114 | 0% | $114 |
| Dental Exam - Periodic, Established Patient | $65 | 0% | $65 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $231 | 0% | $231 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $285 | 0% | $285 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $291 | 0% | $291 |
| Dental Filling - White (Resin): One Surface, Anterior | $213 | 0% | $213 |
| Dental Filling - White (Resin): One Surface, Posterior | $231 | 0% | $231 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $359 | 0% | $359 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $257 | 0% | $257 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $291 | 0% | $291 |
| Flouride - Topical Varnish Application | $95 | 0% | $95 |
| Maintenance Therapy - Periodontal | $176 | 0% | $176 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $96 | 0% | $96 |
| Root Canal - Bicuspid Tooth | $1,103 | 0% | $1,103 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $126 | 0% | $126 |
| Tooth Extraction - Elevation and/or Forceps Removal | $240 | 0% | $240 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | 0% | $33 |
| X-Ray - Complete Intraoral Series | $228 | 0% | $228 |
| X-Ray - Four Images, Bitewings | $83 | 0% | $83 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $118 | 0% | $118 |
| X-Ray - Whole Mouth from Outside Mouth | $145 | 0% | $145 |
