| Dental Cleaning - Adult | $126 | 0% | $126 |
| Dental Cleaning - Child | $110 | 0% | $110 |
| Dental Exam - Comprehensive | $116 | 0% | $116 |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | 0% | $189 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $383 | 0% | $383 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $310 | 0% | $310 |
| Dental Filling - White (Resin): One Surface, Posterior | $231 | 0% | $231 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $284 | 0% | $284 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $310 | 0% | $310 |
| Flouride - Topical Varnish Application | $63 | 0% | $63 |
| Maintenance Therapy - Periodontal | $184 | 0% | $184 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $326 | 0% | $326 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $110 | 0% | $110 |
| Root Canal - Molar | $1,575 | 0% | $1,575 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $84 | 0% | $84 |
| Tooth Extraction - Elevation and/or Forceps Removal | $247 | 0% | $247 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
| X-Ray - Complete Intraoral Series | $320 | 0% | $320 |
| X-Ray - Four Images, Bitewings | $89 | 0% | $89 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
| X-Ray - Two Images, Bitewings | $68 | 0% | $68 |
| X-Ray - Whole Mouth from Outside Mouth | $163 | 0% | $163 |
