| Dental Cleaning - Adult | $123 | 0% | $123 |
| Dental Cleaning - Child | $98 | 0% | $98 |
| Dental Exam - Periodic, Established Patient | $74 | 0% | $74 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $163 | 0% | $163 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $225 | 0% | $225 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $197 | 0% | $197 |
| Dental Filling - White (Resin): One Surface, Anterior | $161 | 0% | $161 |
| Dental Filling - White (Resin): One Surface, Posterior | $172 | 0% | $172 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $252 | 0% | $252 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $187 | 0% | $187 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $208 | 0% | $208 |
| Flouride - Topical Varnish Application | $43 | 0% | $43 |
| Fluoride - Topical Application | $43 | 0% | $43 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $200 | 0% | $200 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $66 | 0% | $66 |
| Root Canal - Anterior Tooth | $1,097 | 0% | $1,097 |
| Root Canal - Bicuspid Tooth | $1,155 | 0% | $1,155 |
| Root Canal - Molar | $1,336 | 0% | $1,336 |
| Tooth Extraction - Elevation and/or Forceps Removal | $233 | 0% | $233 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
| X-Ray - Complete Intraoral Series | $226 | 0% | $226 |
| X-Ray - Four Images, Bitewings | $70 | 0% | $70 |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
| X-Ray - Two Images, Bitewings | $47 | 0% | $47 |
| X-Ray - Whole Mouth from Outside Mouth | $179 | 0% | $179 |
