| Dental Cleaning - Adult | $105 | 0% | $105 |
| Dental Cleaning - Child | $120 | 0% | $120 |
| Dental Exam - Comprehensive | $100 | 0% | $100 |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $205 | 0% | $205 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $327 | 0% | $327 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | 0% | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $196 | 0% | $196 |
| Dental Filling - White (Resin): One Surface, Posterior | $205 | 0% | $205 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $327 | 0% | $327 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $256 | 0% | $256 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
| Flouride - Topical Varnish Application | $51 | 0% | $51 |
| Fluoride - Topical Application | $69 | 0% | $69 |
| Maintenance Therapy - Periodontal | $197 | 0% | $197 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $281 | 0% | $281 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $86 | 0% | $86 |
| Root Canal - Anterior Tooth | $819 | 0% | $819 |
| Root Canal - Bicuspid Tooth | $951 | 0% | $951 |
| Root Canal - Molar | $1,142 | 0% | $1,142 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $80 | 0% | $80 |
| Tooth Extraction - Elevation and/or Forceps Removal | $194 | 0% | $194 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $17 | 0% | $17 |
| X-Ray - Complete Intraoral Series | $146 | 0% | $146 |
| X-Ray - Four Images, Bitewings | $72 | 0% | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $33 | 0% | $33 |
| X-Ray - Two Images, Bitewings | $72 | 0% | $72 |
| X-Ray - Whole Mouth from Outside Mouth | $124 | 0% | $124 |
