| Dental Cleaning - Adult | $138 | 0% | $138 |
| Dental Cleaning - Child | $97 | 0% | $97 |
| Dental Exam - Comprehensive | $105 | 0% | $105 |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $260 | 0% | $260 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $358 | 0% | $358 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $284 | 0% | $284 |
| Dental Filling - White (Resin): One Surface, Anterior | $218 | 0% | $218 |
| Dental Filling - White (Resin): One Surface, Posterior | $260 | 0% | $260 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $358 | 0% | $358 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $242 | 0% | $242 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $284 | 0% | $284 |
| Fluoride - Topical Application | $63 | 0% | $63 |
| Maintenance Therapy - Periodontal | $353 | 0% | $353 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $310 | 0% | $310 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $164 | 0% | $164 |
| Root Canal - Anterior Tooth | $1,024 | 0% | $1,024 |
| Root Canal - Bicuspid Tooth | $1,234 | 0% | $1,234 |
| Root Canal - Molar | $1,449 | 0% | $1,449 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $84 | 0% | $84 |
| Tooth Extraction - Elevation and/or Forceps Removal | $263 | 0% | $263 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | 0% | $38 |
| X-Ray - Complete Intraoral Series | $196 | 0% | $196 |
| X-Ray - Four Images, Bitewings | $91 | 0% | $91 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
| X-Ray - Two Images, Bitewings | $68 | 0% | $68 |
| X-Ray - Whole Mouth from Outside Mouth | $200 | 0% | $200 |
