| Dental Cleaning - Adult | $145 | 0% | $145 |
| Dental Cleaning - Child | $100 | 0% | $100 |
| Dental Exam - Comprehensive | $99 | 0% | $99 |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $185 | 0% | $185 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $290 | 0% | $290 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $227 | 0% | $227 |
| Dental Filling - White (Resin): One Surface, Posterior | $204 | 0% | $204 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $332 | 0% | $332 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $215 | 0% | $215 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $242 | 0% | $242 |
| Fluoride - Topical Application | $71 | 0% | $71 |
| Maintenance Therapy - Periodontal | $156 | 0% | $156 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $281 | 0% | $281 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $87 | 0% | $87 |
| Root Canal - Bicuspid Tooth | $1,300 | 0% | $1,300 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | 0% | $68 |
| Tooth Extraction - Elevation and/or Forceps Removal | $221 | 0% | $221 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $67 | 0% | $67 |
| X-Ray - Complete Intraoral Series | $197 | 0% | $197 |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
