| Dental Cleaning - Adult | $130 | 0% | $130 |
| Dental Cleaning - Child | $110 | 0% | $110 |
| Dental Exam - Comprehensive | $103 | 0% | $103 |
| Dental Exam - Periodic, Established Patient | $61 | 0% | $61 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $244 | 0% | $244 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $376 | 0% | $376 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $314 | 0% | $314 |
| Dental Filling - White (Resin): One Surface, Anterior | $222 | 0% | $222 |
| Dental Filling - White (Resin): One Surface, Posterior | $244 | 0% | $244 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $376 | 0% | $376 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $284 | 0% | $284 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $314 | 0% | $314 |
| Fluoride - Topical Application | $46 | 0% | $46 |
| Maintenance Therapy - Periodontal | $174 | 0% | $174 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $308 | 0% | $308 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | 0% | $103 |
| Root Canal - Anterior Tooth | $1,037 | 0% | $1,037 |
| Root Canal - Bicuspid Tooth | $1,281 | 0% | $1,281 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | 0% | $69 |
| Tooth Extraction - Elevation and/or Forceps Removal | $227 | 0% | $227 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $43 | 0% | $43 |
| X-Ray - Complete Intraoral Series | $184 | 0% | $184 |
| X-Ray - Four Images, Bitewings | $83 | 0% | $83 |
| X-Ray - Intraoral, Periapical Radiographic Image | $45 | 0% | $45 |
| X-Ray - Two Images, Bitewings | $62 | 0% | $62 |
| X-Ray - Whole Mouth from Outside Mouth | $161 | 0% | $161 |
