| Dental Cleaning - Adult | $105 | 0% | $105 |
| Dental Cleaning - Child | $120 | 0% | $120 |
| Dental Exam - Comprehensive | $88 | 0% | $88 |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $180 | 0% | $180 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $281 | 0% | $281 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $226 | 0% | $226 |
| Dental Filling - White (Resin): One Surface, Anterior | $176 | 0% | $176 |
| Dental Filling - White (Resin): One Surface, Posterior | $180 | 0% | $180 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $281 | 0% | $281 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $223 | 0% | $223 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $226 | 0% | $226 |
| Fluoride - Topical Application | $57 | 0% | $57 |
| Maintenance Therapy - Periodontal | $212 | 0% | $212 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $287 | 0% | $287 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $78 | 0% | $78 |
| Root Canal - Molar | $1,108 | 0% | $1,108 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $80 | 0% | $80 |
| Tooth Extraction - Elevation and/or Forceps Removal | $188 | 0% | $188 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
| X-Ray - Complete Intraoral Series | $217 | 0% | $217 |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $45 | 0% | $45 |
| X-Ray - Whole Mouth from Outside Mouth | $146 | 0% | $146 |
