| Dental Cleaning - Adult | $103 | 0% | $103 |
| Dental Cleaning - Child | $79 | 0% | $79 |
| Dental Exam - Comprehensive | $100 | 0% | $100 |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $179 | 0% | $179 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $294 | 0% | $294 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $189 | 0% | $189 |
| Dental Filling - White (Resin): One Surface, Anterior | $179 | 0% | $179 |
| Dental Filling - White (Resin): One Surface, Posterior | $179 | 0% | $179 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $294 | 0% | $294 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $222 | 0% | $222 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $247 | 0% | $247 |
| Flouride - Topical Varnish Application | $40 | 0% | $40 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $236 | 0% | $236 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $83 | 0% | $83 |
| Root Canal - Anterior Tooth | $788 | 0% | $788 |
| Root Canal - Bicuspid Tooth | $940 | 0% | $940 |
| Root Canal - Molar | $1,045 | 0% | $1,045 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $47 | 0% | $47 |
| Tooth Extraction - Elevation and/or Forceps Removal | $186 | 0% | $186 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $21 | 0% | $21 |
| X-Ray - Complete Intraoral Series | $142 | 0% | $142 |
| X-Ray - Four Images, Bitewings | $69 | 0% | $69 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
| X-Ray - Whole Mouth from Outside Mouth | $128 | 0% | $128 |
