| Dental Cleaning - Adult | $114 | 0% | $114 |
| Dental Cleaning - Child | $85 | 0% | $85 |
| Dental Exam - Comprehensive | $88 | 0% | $88 |
| Dental Exam - Periodic, Established Patient | $64 | 0% | $64 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $175 | 0% | $175 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $290 | 0% | $290 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $240 | 0% | $240 |
| Dental Filling - White (Resin): One Surface, Anterior | $194 | 0% | $194 |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | 0% | $221 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $318 | 0% | $318 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $228 | 0% | $228 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $240 | 0% | $240 |
| Fluoride - Topical Application | $54 | 0% | $54 |
| Maintenance Therapy - Periodontal | $170 | 0% | $170 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $255 | 0% | $255 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | 0% | $101 |
| Root Canal - Anterior Tooth | $1,092 | 0% | $1,092 |
| Root Canal - Molar | $1,488 | 0% | $1,488 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $70 | 0% | $70 |
| Tooth Extraction - Elevation and/or Forceps Removal | $204 | 0% | $204 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
| X-Ray - Complete Intraoral Series | $161 | 0% | $161 |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $56 | 0% | $56 |
| X-Ray - Whole Mouth from Outside Mouth | $138 | 0% | $138 |
