| Dental Cleaning - Adult | $124 | 0% | $124 |
| Dental Cleaning - Child | $96 | 0% | $96 |
| Dental Exam - Comprehensive | $124 | 0% | $124 |
| Dental Exam - Periodic, Established Patient | $62 | 0% | $62 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $239 | 0% | $239 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $412 | 0% | $412 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $328 | 0% | $328 |
| Dental Filling - White (Resin): One Surface, Anterior | $230 | 0% | $230 |
| Dental Filling - White (Resin): One Surface, Posterior | $256 | 0% | $256 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $412 | 0% | $412 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $288 | 0% | $288 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $328 | 0% | $328 |
| Fluoride - Topical Application | $48 | 0% | $48 |
| Maintenance Therapy - Periodontal | $194 | 0% | $194 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $337 | 0% | $337 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $106 | 0% | $106 |
| Root Canal - Bicuspid Tooth | $1,182 | 0% | $1,182 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $78 | 0% | $78 |
| Tooth Extraction - Elevation and/or Forceps Removal | $243 | 0% | $243 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | 0% | $36 |
| X-Ray - Complete Intraoral Series | $181 | 0% | $181 |
| X-Ray - Four Images, Bitewings | $87 | 0% | $87 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
| X-Ray - Two Images, Bitewings | $62 | 0% | $62 |
| X-Ray - Whole Mouth from Outside Mouth | $160 | 0% | $160 |
