| Dental Cleaning - Adult | $225 | 0% | $225 |
| Dental Exam - Comprehensive | $110 | 0% | $110 |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $221 | 0% | $221 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $296 | 0% | $296 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $260 | 0% | $260 |
| Dental Filling - White (Resin): One Surface, Anterior | $221 | 0% | $221 |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | 0% | $221 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $344 | 0% | $344 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $252 | 0% | $252 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $279 | 0% | $279 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $75 | 0% | $75 |
| Root Canal - Anterior Tooth | $985 | 0% | $985 |
| Tooth Extraction - Elevation and/or Forceps Removal | $315 | 0% | $315 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Complete Intraoral Series | $200 | 0% | $200 |
| X-Ray - Four Images, Bitewings | $160 | 0% | $160 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
| X-Ray - Whole Mouth from Outside Mouth | $142 | 0% | $142 |
