| Dental Cleaning - Adult | $119 | 0% | $119 |
| Dental Cleaning - Child | $91 | 0% | $91 |
| Dental Exam - Comprehensive | $104 | 0% | $104 |
| Dental Exam - Periodic, Established Patient | $55 | 0% | $55 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $185 | 0% | $185 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $371 | 0% | $371 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $259 | 0% | $259 |
| Dental Filling - White (Resin): One Surface, Anterior | $199 | 0% | $199 |
| Dental Filling - White (Resin): One Surface, Posterior | $205 | 0% | $205 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $371 | 0% | $371 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $208 | 0% | $208 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $286 | 0% | $286 |
| Flouride - Topical Varnish Application | $50 | 0% | $50 |
| Fluoride - Topical Application | $47 | 0% | $47 |
| Maintenance Therapy - Periodontal | $193 | 0% | $193 |
| 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 | $104 | 0% | $104 |
| Root Canal - Anterior Tooth | $1,125 | 0% | $1,125 |
| Root Canal - Bicuspid Tooth | $1,210 | 0% | $1,210 |
| Root Canal - Molar | $1,110 | 0% | $1,110 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $70 | 0% | $70 |
| Tooth Extraction - Elevation and/or Forceps Removal | $156 | 0% | $156 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
| X-Ray - Complete Intraoral Series | $158 | 0% | $158 |
| X-Ray - Four Images, Bitewings | $79 | 0% | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
| X-Ray - Two Images, Bitewings | $56 | 0% | $56 |
| X-Ray - Whole Mouth from Outside Mouth | $161 | 0% | $161 |
