| Dental Cleaning - Adult | $135 | 0% | $135 |
| Dental Cleaning - Child | $99 | 0% | $99 |
| Dental Exam - Comprehensive | $113 | 0% | $113 |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $236 | 0% | $236 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $363 | 0% | $363 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $176 | 0% | $176 |
| Dental Filling - White (Resin): One Surface, Anterior | $297 | 0% | $297 |
| Dental Filling - White (Resin): One Surface, Posterior | $224 | 0% | $224 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $727 | 0% | $727 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $256 | 0% | $256 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $286 | 0% | $286 |
| Flouride - Topical Varnish Application | $50 | 0% | $50 |
| Fluoride - Topical Application | $40 | 0% | $40 |
| Maintenance Therapy - Periodontal | $192 | 0% | $192 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $302 | 0% | $302 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $108 | 0% | $108 |
| Root Canal - Bicuspid Tooth | $1,328 | 0% | $1,328 |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | 0% | $184 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | 0% | $38 |
| X-Ray - Complete Intraoral Series | $186 | 0% | $186 |
| X-Ray - Four Images, Bitewings | $91 | 0% | $91 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $82 | 0% | $82 |
