| Dental Cleaning - Adult | $148 | 0% | $148 |
| Dental Cleaning - Child | $131 | 0% | $131 |
| Dental Exam - Comprehensive | $119 | 0% | $119 |
| Dental Exam - Periodic, Established Patient | $82 | 0% | $82 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $227 | 0% | $227 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $426 | 0% | $426 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $313 | 0% | $313 |
| Dental Filling - White (Resin): One Surface, Anterior | $227 | 0% | $227 |
| Dental Filling - White (Resin): One Surface, Posterior | $227 | 0% | $227 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $426 | 0% | $426 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $313 | 0% | $313 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $313 | 0% | $313 |
| Fluoride - Topical Application | $68 | 0% | $68 |
| Maintenance Therapy - Periodontal | $227 | 0% | $227 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $426 | 0% | $426 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $97 | 0% | $97 |
| Root Canal - Bicuspid Tooth | $1,476 | 0% | $1,476 |
| Tooth Extraction - Elevation and/or Forceps Removal | $273 | 0% | $273 |
| X-Ray - Complete Intraoral Series | $317 | 0% | $317 |
| X-Ray - Four Images, Bitewings | $107 | 0% | $107 |
| X-Ray - Intraoral, Periapical Radiographic Image | $47 | 0% | $47 |
| X-Ray - Two Images, Bitewings | $80 | 0% | $80 |
| X-Ray - Whole Mouth from Outside Mouth | $210 | 0% | $210 |
