| Dental Cleaning - Adult | $104 | 0% | $104 |
| Dental Cleaning - Child | $84 | 0% | $84 |
| Dental Exam - Comprehensive | $90 | 0% | $90 |
| Dental Exam - Periodic, Established Patient | $64 | 0% | $64 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $188 | 0% | $188 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $340 | 0% | $340 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $261 | 0% | $261 |
| Dental Filling - White (Resin): One Surface, Anterior | $164 | 0% | $164 |
| Dental Filling - White (Resin): One Surface, Posterior | $188 | 0% | $188 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $340 | 0% | $340 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $201 | 0% | $201 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $261 | 0% | $261 |
| Flouride - Topical Varnish Application | $43 | 0% | $43 |
| Fluoride - Topical Application | $43 | 0% | $43 |
| Maintenance Therapy - Periodontal | $150 | 0% | $150 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $275 | 0% | $275 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | 0% | $88 |
| Root Canal - Anterior Tooth | $852 | 0% | $852 |
| Root Canal - Bicuspid Tooth | $970 | 0% | $970 |
| Root Canal - Molar | $1,814 | 0% | $1,814 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $158 | 0% | $158 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
| X-Ray - Complete Intraoral Series | $145 | 0% | $145 |
| X-Ray - Four Images, Bitewings | $80 | 0% | $80 |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
| X-Ray - Two Images, Bitewings | $65 | 0% | $65 |
| X-Ray - Whole Mouth from Outside Mouth | $145 | 0% | $145 |
