| Dental Cleaning - Adult | $105 | 0% | $105 |
| Dental Cleaning - Child | $80 | 0% | $80 |
| Dental Exam - Comprehensive | $100 | 0% | $100 |
| Dental Exam - Periodic, Established Patient | $55 | 0% | $55 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $242 | 0% | $242 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $373 | 0% | $373 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $305 | 0% | $305 |
| Dental Filling - White (Resin): One Surface, Anterior | $194 | 0% | $194 |
| Dental Filling - White (Resin): One Surface, Posterior | $242 | 0% | $242 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $373 | 0% | $373 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $236 | 0% | $236 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $305 | 0% | $305 |
| Fluoride - Topical Application | $44 | 0% | $44 |
| Maintenance Therapy - Periodontal | $336 | 0% | $336 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $284 | 0% | $284 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $181 | 0% | $181 |
| Root Canal - Anterior Tooth | $961 | 0% | $961 |
| Root Canal - Bicuspid Tooth | $2,226 | 0% | $2,226 |
| Root Canal - Molar | $1,349 | 0% | $1,349 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | 0% | $60 |
| Tooth Extraction - Elevation and/or Forceps Removal | $231 | 0% | $231 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
| X-Ray - Complete Intraoral Series | $168 | 0% | $168 |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $29 | 0% | $29 |
| X-Ray - Two Images, Bitewings | $43 | 0% | $43 |
