| Dental Cleaning - Adult | $117 | 0% | $117 |
| Dental Cleaning - Child | $88 | 0% | $88 |
| Dental Exam - Comprehensive | $96 | 0% | $96 |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $215 | 0% | $215 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $334 | 0% | $334 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | 0% | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $168 | 0% | $168 |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | 0% | $189 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $334 | 0% | $334 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $208 | 0% | $208 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $265 | 0% | $265 |
| Flouride - Topical Varnish Application | $44 | 0% | $44 |
| Fluoride - Topical Application | $42 | 0% | $42 |
| Maintenance Therapy - Periodontal | $146 | 0% | $146 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $309 | 0% | $309 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
| Root Canal - Anterior Tooth | $940 | 0% | $940 |
| Root Canal - Bicuspid Tooth | $945 | 0% | $945 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $57 | 0% | $57 |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | 0% | $184 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
| X-Ray - Complete Intraoral Series | $177 | 0% | $177 |
| X-Ray - Four Images, Bitewings | $77 | 0% | $77 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
| X-Ray - Two Images, Bitewings | $51 | 0% | $51 |
| X-Ray - Whole Mouth from Outside Mouth | $126 | 0% | $126 |
