| Dental Cleaning - Adult | $126 | 0% | $126 |
| Dental Cleaning - Child | $100 | 0% | $100 |
| Dental Exam - Comprehensive | $131 | 0% | $131 |
| Dental Exam - Periodic, Established Patient | $68 | 0% | $68 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $223 | 0% | $223 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $404 | 0% | $404 |
| Dental Filling - White (Resin): One Surface, Anterior | $194 | 0% | $194 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $404 | 0% | $404 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $236 | 0% | $236 |
| Maintenance Therapy - Periodontal | $179 | 0% | $179 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $331 | 0% | $331 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | 0% | $105 |
| Root Canal - Anterior Tooth | $1,381 | 0% | $1,381 |
| Root Canal - Bicuspid Tooth | $1,486 | 0% | $1,486 |
| Root Canal - Molar | $1,696 | 0% | $1,696 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | 0% | $68 |
| Tooth Extraction - Elevation and/or Forceps Removal | $231 | 0% | $231 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
| X-Ray - Complete Intraoral Series | $184 | 0% | $184 |
| X-Ray - Four Images, Bitewings | $89 | 0% | $89 |
| X-Ray - Intraoral, Periapical Radiographic Image | $50 | 0% | $50 |
| X-Ray - Two Images, Bitewings | $47 | 0% | $47 |
| X-Ray - Whole Mouth from Outside Mouth | $168 | 0% | $168 |
