| Dental Cleaning - Adult | $121 | 0% | $121 |
| Dental Cleaning - Child | $95 | 0% | $95 |
| Dental Exam - Comprehensive | $105 | 0% | $105 |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $174 | 0% | $174 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | 0% | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | 0% | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $181 | 0% | $181 |
| Dental Filling - White (Resin): One Surface, Posterior | $210 | 0% | $210 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $362 | 0% | $362 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $226 | 0% | $226 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $284 | 0% | $284 |
| Flouride - Topical Varnish Application | $47 | 0% | $47 |
| Fluoride - Topical Application | $45 | 0% | $45 |
| Maintenance Therapy - Periodontal | $158 | 0% | $158 |
| 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 | $96 | 0% | $96 |
| Root Canal - Anterior Tooth | $911 | 0% | $911 |
| Root Canal - Bicuspid Tooth | $979 | 0% | $979 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | 0% | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $215 | 0% | $215 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Complete Intraoral Series | $189 | 0% | $189 |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
| X-Ray - Two Images, Bitewings | $84 | 0% | $84 |
| X-Ray - Whole Mouth from Outside Mouth | $142 | 0% | $142 |
