| Dental Cleaning - Adult | $107 | 0% | $107 |
| Dental Cleaning - Child | $86 | 0% | $86 |
| Dental Exam - Comprehensive | $111 | 0% | $111 |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $188 | 0% | $188 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $249 | 0% | $249 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $282 | 0% | $282 |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | 0% | $184 |
| Dental Filling - White (Resin): One Surface, Posterior | $198 | 0% | $198 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $352 | 0% | $352 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $259 | 0% | $259 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $282 | 0% | $282 |
| Flouride - Topical Varnish Application | $43 | 0% | $43 |
| Fluoride - Topical Application | $43 | 0% | $43 |
| Maintenance Therapy - Periodontal | $151 | 0% | $151 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $308 | 0% | $308 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
| Root Canal - Anterior Tooth | $877 | 0% | $877 |
| Root Canal - Bicuspid Tooth | $979 | 0% | $979 |
| Root Canal - Molar | $1,248 | 0% | $1,248 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | 0% | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | 0% | $184 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Complete Intraoral Series | $148 | 0% | $148 |
| X-Ray - Four Images, Bitewings | $72 | 0% | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $51 | 0% | $51 |
| X-Ray - Whole Mouth from Outside Mouth | $131 | 0% | $131 |
