| Dental Cleaning - Adult | $116 | 0% | $116 |
| Dental Cleaning - Child | $95 | 0% | $95 |
| Dental Exam - Comprehensive | $124 | 0% | $124 |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $231 | 0% | $231 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $431 | 0% | $431 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $290 | 0% | $290 |
| Dental Filling - White (Resin): One Surface, Anterior | $205 | 0% | $205 |
| Dental Filling - White (Resin): One Surface, Posterior | $231 | 0% | $231 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $431 | 0% | $431 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $242 | 0% | $242 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $305 | 0% | $305 |
| Flouride - Topical Varnish Application | $50 | 0% | $50 |
| Fluoride - Topical Application | $47 | 0% | $47 |
| Maintenance Therapy - Periodontal | $170 | 0% | $170 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $357 | 0% | $357 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $112 | 0% | $112 |
| Root Canal - Anterior Tooth | $887 | 0% | $887 |
| Root Canal - Bicuspid Tooth | $1,622 | 0% | $1,622 |
| Root Canal - Molar | $1,313 | 0% | $1,313 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $65 | 0% | $65 |
| Tooth Extraction - Elevation and/or Forceps Removal | $226 | 0% | $226 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $47 | 0% | $47 |
| X-Ray - Complete Intraoral Series | $165 | 0% | $165 |
| X-Ray - Four Images, Bitewings | $89 | 0% | $89 |
| X-Ray - Intraoral, Periapical Radiographic Image | $45 | 0% | $45 |
| X-Ray - Two Images, Bitewings | $65 | 0% | $65 |
| X-Ray - Whole Mouth from Outside Mouth | $158 | 0% | $158 |
