| Dental Cleaning - Adult | $105 | 0% | $105 |
| Dental Cleaning - Child | $105 | 0% | $105 |
| Dental Exam - Comprehensive | $97 | 0% | $97 |
| Dental Exam - Periodic, Established Patient | $55 | 0% | $55 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | 0% | $208 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | 0% | $326 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $234 | 0% | $234 |
| Dental Filling - White (Resin): One Surface, Anterior | $187 | 0% | $187 |
| Dental Filling - White (Resin): One Surface, Posterior | $202 | 0% | $202 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $361 | 0% | $361 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | 0% | $271 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $292 | 0% | $292 |
| Flouride - Topical Varnish Application | $45 | 0% | $45 |
| Fluoride - Topical Application | $48 | 0% | $48 |
| Maintenance Therapy - Periodontal | $184 | 0% | $184 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $299 | 0% | $299 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $97 | 0% | $97 |
| Root Canal - Anterior Tooth | $877 | 0% | $877 |
| Root Canal - Bicuspid Tooth | $1,050 | 0% | $1,050 |
| Root Canal - Molar | $1,378 | 0% | $1,378 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $215 | 0% | $215 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $40 | 0% | $40 |
| X-Ray - Complete Intraoral Series | $167 | 0% | $167 |
| X-Ray - Four Images, Bitewings | $76 | 0% | $76 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
| X-Ray - Two Images, Bitewings | $60 | 0% | $60 |
| X-Ray - Whole Mouth from Outside Mouth | $137 | 0% | $137 |
