| Dental Cleaning - Adult | $107 | 0% | $107 |
| Dental Cleaning - Child | $107 | 0% | $107 |
| Dental Exam - Comprehensive | $97 | 0% | $97 |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $263 | 0% | $263 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | 0% | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $305 | 0% | $305 |
| Dental Filling - White (Resin): One Surface, Anterior | $263 | 0% | $263 |
| Dental Filling - White (Resin): One Surface, Posterior | $263 | 0% | $263 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | 0% | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $305 | 0% | $305 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $305 | 0% | $305 |
| Flouride - Topical Varnish Application | $51 | 0% | $51 |
| Fluoride - Topical Application | $43 | 0% | $43 |
| Maintenance Therapy - Periodontal | $164 | 0% | $164 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $302 | 0% | $302 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $93 | 0% | $93 |
| Root Canal - Anterior Tooth | $1,890 | 0% | $1,890 |
| Root Canal - Bicuspid Tooth | $2,144 | 0% | $2,144 |
| Root Canal - Molar | $1,933 | 0% | $1,933 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | 0% | $61 |
| Tooth Extraction - Elevation and/or Forceps Removal | $186 | 0% | $186 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
| X-Ray - Complete Intraoral Series | $158 | 0% | $158 |
| X-Ray - Four Images, Bitewings | $72 | 0% | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $51 | 0% | $51 |
| X-Ray - Whole Mouth from Outside Mouth | $131 | 0% | $131 |
