| Dental Cleaning - Adult | $170 | 0% | $170 |
| Dental Cleaning - Child | $120 | 0% | $120 |
| Dental Exam - Comprehensive | $132 | 0% | $132 |
| Dental Exam - Periodic, Established Patient | $82 | 0% | $82 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $228 | 0% | $228 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $359 | 0% | $359 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $292 | 0% | $292 |
| Dental Filling - White (Resin): One Surface, Anterior | $246 | 0% | $246 |
| Dental Filling - White (Resin): One Surface, Posterior | $267 | 0% | $267 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $408 | 0% | $408 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $328 | 0% | $328 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $342 | 0% | $342 |
| Flouride - Topical Varnish Application | $74 | 0% | $74 |
| Fluoride - Topical Application | $78 | 0% | $78 |
| Maintenance Therapy - Periodontal | $233 | 0% | $233 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $435 | 0% | $435 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $127 | 0% | $127 |
| Root Canal - Anterior Tooth | $1,455 | 0% | $1,455 |
| Root Canal - Bicuspid Tooth | $1,621 | 0% | $1,621 |
| Root Canal - Molar | $1,985 | 0% | $1,985 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $88 | 0% | $88 |
| Tooth Extraction - Elevation and/or Forceps Removal | $286 | 0% | $286 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
| X-Ray - Complete Intraoral Series | $244 | 0% | $244 |
| X-Ray - Four Images, Bitewings | $109 | 0% | $109 |
| X-Ray - Intraoral, Periapical Radiographic Image | $48 | 0% | $48 |
| X-Ray - Two Images, Bitewings | $66 | 0% | $66 |
| X-Ray - Whole Mouth from Outside Mouth | $182 | 0% | $182 |
