| Dental Cleaning - Adult | $120 | 0% | $120 |
| Dental Cleaning - Child | $95 | 0% | $95 |
| Dental Exam - Comprehensive | $113 | 0% | $113 |
| Dental Exam - Periodic, Established Patient | $68 | 0% | $68 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $174 | 0% | $174 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $273 | 0% | $273 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $217 | 0% | $217 |
| Dental Filling - White (Resin): One Surface, Anterior | $204 | 0% | $204 |
| Dental Filling - White (Resin): One Surface, Posterior | $221 | 0% | $221 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $394 | 0% | $394 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $250 | 0% | $250 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $303 | 0% | $303 |
| Flouride - Topical Varnish Application | $51 | 0% | $51 |
| Maintenance Therapy - Periodontal | $177 | 0% | $177 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $323 | 0% | $323 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $102 | 0% | $102 |
| Root Canal - Anterior Tooth | $1,976 | 0% | $1,976 |
| Root Canal - Bicuspid Tooth | $1,126 | 0% | $1,126 |
| Root Canal - Molar | $1,398 | 0% | $1,398 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | 0% | $69 |
| Tooth Extraction - Elevation and/or Forceps Removal | $215 | 0% | $215 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
| X-Ray - Complete Intraoral Series | $177 | 0% | $177 |
| X-Ray - Four Images, Bitewings | $85 | 0% | $85 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
