| Dental Cleaning - Adult | $109 | 0% | $109 |
| Dental Cleaning - Child | $89 | 0% | $89 |
| Dental Exam - Comprehensive | $104 | 0% | $104 |
| Dental Exam - Periodic, Established Patient | $59 | 0% | $59 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $216 | 0% | $216 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $374 | 0% | $374 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $276 | 0% | $276 |
| Dental Filling - White (Resin): One Surface, Anterior | $202 | 0% | $202 |
| Dental Filling - White (Resin): One Surface, Posterior | $218 | 0% | $218 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $374 | 0% | $374 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $243 | 0% | $243 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $276 | 0% | $276 |
| Flouride - Topical Varnish Application | $51 | 0% | $51 |
| Fluoride - Topical Application | $44 | 0% | $44 |
| Maintenance Therapy - Periodontal | $166 | 0% | $166 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $298 | 0% | $298 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | 0% | $92 |
| Root Canal - Anterior Tooth | $933 | 0% | $933 |
| Root Canal - Bicuspid Tooth | $1,059 | 0% | $1,059 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $66 | 0% | $66 |
| Tooth Extraction - Elevation and/or Forceps Removal | $214 | 0% | $214 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | 0% | $30 |
| X-Ray - Complete Intraoral Series | $159 | 0% | $159 |
| X-Ray - Four Images, Bitewings | $79 | 0% | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $57 | 0% | $57 |
| X-Ray - Whole Mouth from Outside Mouth | $147 | 0% | $147 |
