| Dental Cleaning - Adult | $110 | 0% | $110 |
| Dental Cleaning - Child | $88 | 0% | $88 |
| Dental Exam - Comprehensive | $95 | 0% | $95 |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $211 | 0% | $211 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $363 | 0% | $363 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $294 | 0% | $294 |
| Dental Filling - White (Resin): One Surface, Anterior | $186 | 0% | $186 |
| Dental Filling - White (Resin): One Surface, Posterior | $211 | 0% | $211 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $363 | 0% | $363 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $223 | 0% | $223 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $294 | 0% | $294 |
| Flouride - Topical Varnish Application | $43 | 0% | $43 |
| Fluoride - Topical Application | $43 | 0% | $43 |
| Maintenance Therapy - Periodontal | $177 | 0% | $177 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $303 | 0% | $303 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
| Root Canal - Anterior Tooth | $1,350 | 0% | $1,350 |
| Root Canal - Bicuspid Tooth | $1,049 | 0% | $1,049 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | 0% | $61 |
| Tooth Extraction - Elevation and/or Forceps Removal | $211 | 0% | $211 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
| X-Ray - Complete Intraoral Series | $151 | 0% | $151 |
| X-Ray - Four Images, Bitewings | $75 | 0% | $75 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
| X-Ray - Two Images, Bitewings | $54 | 0% | $54 |
