| Dental Cleaning - Adult | $118 | 0% | $118 |
| Dental Cleaning - Child | $91 | 0% | $91 |
| Dental Exam - Comprehensive | $101 | 0% | $101 |
| Dental Exam - Periodic, Established Patient | $62 | 0% | $62 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $278 | 0% | $278 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $361 | 0% | $361 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $278 | 0% | $278 |
| Dental Filling - White (Resin): One Surface, Anterior | $208 | 0% | $208 |
| Dental Filling - White (Resin): One Surface, Posterior | $209 | 0% | $209 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $361 | 0% | $361 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $228 | 0% | $228 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $278 | 0% | $278 |
| Fluoride - Topical Application | $47 | 0% | $47 |
| Maintenance Therapy - Periodontal | $180 | 0% | $180 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $328 | 0% | $328 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $96 | 0% | $96 |
| Root Canal - Bicuspid Tooth | $1,179 | 0% | $1,179 |
| Root Canal - Molar | $1,461 | 0% | $1,461 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $64 | 0% | $64 |
| Tooth Extraction - Elevation and/or Forceps Removal | $254 | 0% | $254 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
| X-Ray - Complete Intraoral Series | $177 | 0% | $177 |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
| X-Ray - Two Images, Bitewings | $90 | 0% | $90 |
| X-Ray - Whole Mouth from Outside Mouth | $152 | 0% | $152 |
