| Dental Cleaning - Adult | $109 | 0% | $109 |
| Dental Cleaning - Child | $83 | 0% | $83 |
| Dental Exam - Comprehensive | $104 | 0% | $104 |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $211 | 0% | $211 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $324 | 0% | $324 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | 0% | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $196 | 0% | $196 |
| Dental Filling - White (Resin): One Surface, Posterior | $211 | 0% | $211 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $326 | 0% | $326 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | 0% | $271 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $269 | 0% | $269 |
| Flouride - Topical Varnish Application | $49 | 0% | $49 |
| Fluoride - Topical Application | $45 | 0% | $45 |
| Maintenance Therapy - Periodontal | $161 | 0% | $161 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $293 | 0% | $293 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
| Root Canal - Anterior Tooth | $889 | 0% | $889 |
| Root Canal - Bicuspid Tooth | $1,026 | 0% | $1,026 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $64 | 0% | $64 |
| Tooth Extraction - Elevation and/or Forceps Removal | $260 | 0% | $260 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
| X-Ray - Complete Intraoral Series | $152 | 0% | $152 |
| X-Ray - Four Images, Bitewings | $76 | 0% | $76 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | 0% | $36 |
| X-Ray - Two Images, Bitewings | $53 | 0% | $53 |
