| Dental Cleaning - Adult | $109 | 0% | $109 |
| Dental Cleaning - Child | $118 | 0% | $118 |
| Dental Exam - Comprehensive | $99 | 0% | $99 |
| Dental Exam - Periodic, Established Patient | $46 | 0% | $46 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $176 | 0% | $176 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $290 | 0% | $290 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $246 | 0% | $246 |
| Dental Filling - White (Resin): One Surface, Anterior | $200 | 0% | $200 |
| Dental Filling - White (Resin): One Surface, Posterior | $194 | 0% | $194 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $313 | 0% | $313 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $265 | 0% | $265 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $271 | 0% | $271 |
| Flouride - Topical Varnish Application | $53 | 0% | $53 |
| Maintenance Therapy - Periodontal | $151 | 0% | $151 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $368 | 0% | $368 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | 0% | $101 |
| Root Canal - Anterior Tooth | $1,092 | 0% | $1,092 |
| Root Canal - Bicuspid Tooth | $1,300 | 0% | $1,300 |
| Root Canal - Molar | $1,758 | 0% | $1,758 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $79 | 0% | $79 |
| Tooth Extraction - Elevation and/or Forceps Removal | $208 | 0% | $208 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $17 | 0% | $17 |
| X-Ray - Complete Intraoral Series | $147 | 0% | $147 |
| X-Ray - Four Images, Bitewings | $77 | 0% | $77 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $55 | 0% | $55 |
| X-Ray - Whole Mouth from Outside Mouth | $147 | 0% | $147 |
