| Dental Cleaning - Adult | $113 | 0% | $113 |
| Dental Cleaning - Child | $89 | 0% | $89 |
| Dental Exam - Comprehensive | $95 | 0% | $95 |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $173 | 0% | $173 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $343 | 0% | $343 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $268 | 0% | $268 |
| Dental Filling - White (Resin): One Surface, Anterior | $210 | 0% | $210 |
| Dental Filling - White (Resin): One Surface, Posterior | $226 | 0% | $226 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $347 | 0% | $347 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $242 | 0% | $242 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $278 | 0% | $278 |
| Fluoride - Topical Application | $49 | 0% | $49 |
| Maintenance Therapy - Periodontal | $166 | 0% | $166 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $289 | 0% | $289 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $90 | 0% | $90 |
| Root Canal - Bicuspid Tooth | $2,079 | 0% | $2,079 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $66 | 0% | $66 |
| Tooth Extraction - Elevation and/or Forceps Removal | $221 | 0% | $221 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
| X-Ray - Complete Intraoral Series | $158 | 0% | $158 |
| X-Ray - Four Images, Bitewings | $78 | 0% | $78 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
