| Dental Cleaning - Adult | $104 | 0% | $104 |
| Dental Cleaning - Child | $84 | 0% | $84 |
| Dental Exam - Comprehensive | $90 | 0% | $90 |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $188 | 0% | $188 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $340 | 0% | $340 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $261 | 0% | $261 |
| Dental Filling - White (Resin): One Surface, Anterior | $168 | 0% | $168 |
| Dental Filling - White (Resin): One Surface, Posterior | $188 | 0% | $188 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $340 | 0% | $340 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $201 | 0% | $201 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $261 | 0% | $261 |
| Flouride - Topical Varnish Application | $41 | 0% | $41 |
| Fluoride - Topical Application | $42 | 0% | $42 |
| Maintenance Therapy - Periodontal | $150 | 0% | $150 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $275 | 0% | $275 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $88 | 0% | $88 |
| Root Canal - Anterior Tooth | $852 | 0% | $852 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $182 | 0% | $182 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
| X-Ray - Complete Intraoral Series | $203 | 0% | $203 |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
| X-Ray - Whole Mouth from Outside Mouth | $131 | 0% | $131 |
