| Dental Cleaning - Adult | $122 | 0% | $122 |
| Dental Cleaning - Child | $96 | 0% | $96 |
| Dental Exam - Comprehensive | $118 | 0% | $118 |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | 0% | $208 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $273 | 0% | $273 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $231 | 0% | $231 |
| Dental Filling - White (Resin): One Surface, Anterior | $218 | 0% | $218 |
| Dental Filling - White (Resin): One Surface, Posterior | $235 | 0% | $235 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $361 | 0% | $361 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $260 | 0% | $260 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $294 | 0% | $294 |
| Flouride - Topical Varnish Application | $51 | 0% | $51 |
| Fluoride - Topical Application | $43 | 0% | $43 |
| Maintenance Therapy - Periodontal | $172 | 0% | $172 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $332 | 0% | $332 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | 0% | $101 |
| Root Canal - Bicuspid Tooth | $1,217 | 0% | $1,217 |
| Root Canal - Molar | $1,453 | 0% | $1,453 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $67 | 0% | $67 |
| Tooth Extraction - Elevation and/or Forceps Removal | $273 | 0% | $273 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
| X-Ray - Complete Intraoral Series | $168 | 0% | $168 |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $61 | 0% | $61 |
