| Dental Cleaning - Adult | $95 | 0% | $95 |
| Dental Cleaning - Child | $68 | 0% | $68 |
| Dental Exam - Comprehensive | $84 | 0% | $84 |
| Dental Exam - Periodic, Established Patient | $48 | 0% | $48 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $173 | 0% | $173 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $273 | 0% | $273 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $221 | 0% | $221 |
| Dental Filling - White (Resin): One Surface, Anterior | $158 | 0% | $158 |
| Dental Filling - White (Resin): One Surface, Posterior | $173 | 0% | $173 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $273 | 0% | $273 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $194 | 0% | $194 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $221 | 0% | $221 |
| Flouride - Topical Varnish Application | $41 | 0% | $41 |
| Fluoride - Topical Application | $38 | 0% | $38 |
| Maintenance Therapy - Periodontal | $252 | 0% | $252 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $237 | 0% | $237 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $80 | 0% | $80 |
| Root Canal - Anterior Tooth | $777 | 0% | $777 |
| Root Canal - Molar | $1,087 | 0% | $1,087 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $46 | 0% | $46 |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | 0% | $184 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $25 | 0% | $25 |
| X-Ray - Complete Intraoral Series | $131 | 0% | $131 |
| X-Ray - Four Images, Bitewings | $67 | 0% | $67 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
| X-Ray - Two Images, Bitewings | $46 | 0% | $46 |
| X-Ray - Whole Mouth from Outside Mouth | $110 | 0% | $110 |
