| Dental Cleaning - Adult | $117 | 0% | $117 |
| Dental Cleaning - Child | $100 | 0% | $100 |
| Dental Exam - Comprehensive | $112 | 0% | $112 |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $214 | 0% | $214 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $374 | 0% | $374 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $289 | 0% | $289 |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | 0% | $184 |
| Dental Filling - White (Resin): One Surface, Posterior | $214 | 0% | $214 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $374 | 0% | $374 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $235 | 0% | $235 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $289 | 0% | $289 |
| Flouride - Topical Varnish Application | $50 | 0% | $50 |
| Maintenance Therapy - Periodontal | $174 | 0% | $174 |
| 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 | $110 | 0% | $110 |
| Root Canal - Molar | $1,654 | 0% | $1,654 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | 0% | $61 |
| Tooth Extraction - Elevation and/or Forceps Removal | $289 | 0% | $289 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
| X-Ray - Complete Intraoral Series | $233 | 0% | $233 |
| X-Ray - Four Images, Bitewings | $88 | 0% | $88 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $61 | 0% | $61 |
| X-Ray - Whole Mouth from Outside Mouth | $145 | 0% | $145 |
