| Dental Cleaning - Adult | $109 | 0% | $109 |
| Dental Cleaning - Child | $88 | 0% | $88 |
| Dental Exam - Comprehensive | $91 | 0% | $91 |
| Dental Exam - Periodic, Established Patient | $56 | 0% | $56 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $201 | 0% | $201 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | 0% | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | 0% | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $169 | 0% | $169 |
| Dental Filling - White (Resin): One Surface, Posterior | $201 | 0% | $201 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | 0% | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $203 | 0% | $203 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
| Flouride - Topical Varnish Application | $50 | 0% | $50 |
| Maintenance Therapy - Periodontal | $151 | 0% | $151 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $289 | 0% | $289 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $75 | 0% | $75 |
| Root Canal - Anterior Tooth | $806 | 0% | $806 |
| Root Canal - Bicuspid Tooth | $820 | 0% | $820 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | 0% | $61 |
| Tooth Extraction - Elevation and/or Forceps Removal | $186 | 0% | $186 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
| X-Ray - Complete Intraoral Series | $148 | 0% | $148 |
| X-Ray - Four Images, Bitewings | $75 | 0% | $75 |
| X-Ray - Intraoral, Periapical Radiographic Image | $33 | 0% | $33 |
| X-Ray - Two Images, Bitewings | $51 | 0% | $51 |
| X-Ray - Whole Mouth from Outside Mouth | $137 | 0% | $137 |
