| Dental Cleaning - Adult | $128 | 0% | $128 |
| Dental Cleaning - Child | $120 | 0% | $120 |
| Dental Exam - Comprehensive | $108 | 0% | $108 |
| Dental Exam - Periodic, Established Patient | $56 | 0% | $56 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $223 | 0% | $223 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $359 | 0% | $359 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $292 | 0% | $292 |
| Dental Filling - White (Resin): One Surface, Anterior | $183 | 0% | $183 |
| Dental Filling - White (Resin): One Surface, Posterior | $223 | 0% | $223 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $377 | 0% | $377 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $243 | 0% | $243 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $292 | 0% | $292 |
| Flouride - Topical Varnish Application | $60 | 0% | $60 |
| Fluoride - Topical Application | $69 | 0% | $69 |
| Maintenance Therapy - Periodontal | $175 | 0% | $175 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $318 | 0% | $318 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $102 | 0% | $102 |
| Root Canal - Anterior Tooth | $1,323 | 0% | $1,323 |
| Root Canal - Bicuspid Tooth | $1,345 | 0% | $1,345 |
| Root Canal - Molar | $1,528 | 0% | $1,528 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $80 | 0% | $80 |
| Tooth Extraction - Elevation and/or Forceps Removal | $212 | 0% | $212 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
| X-Ray - Complete Intraoral Series | $183 | 0% | $183 |
| X-Ray - Four Images, Bitewings | $82 | 0% | $82 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
| X-Ray - Two Images, Bitewings | $76 | 0% | $76 |
| X-Ray - Whole Mouth from Outside Mouth | $169 | 0% | $169 |
