| Dental Cleaning - Adult | $127 | 0% | $127 |
| Dental Cleaning - Child | $71 | 0% | $71 |
| Dental Exam - Comprehensive | $112 | 0% | $112 |
| Dental Exam - Periodic, Established Patient | $46 | 0% | $46 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $177 | 0% | $177 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | 0% | $326 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $184 | 0% | $184 |
| Dental Filling - White (Resin): One Surface, Anterior | $200 | 0% | $200 |
| Dental Filling - White (Resin): One Surface, Posterior | $169 | 0% | $169 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $419 | 0% | $419 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $233 | 0% | $233 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $255 | 0% | $255 |
| Flouride - Topical Varnish Application | $53 | 0% | $53 |
| Fluoride - Topical Application | $34 | 0% | $34 |
| Maintenance Therapy - Periodontal | $190 | 0% | $190 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $340 | 0% | $340 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $109 | 0% | $109 |
| Root Canal - Bicuspid Tooth | $1,299 | 0% | $1,299 |
| Root Canal - Molar | $1,526 | 0% | $1,526 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $51 | 0% | $51 |
| Tooth Extraction - Elevation and/or Forceps Removal | $224 | 0% | $224 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | 0% | $33 |
| X-Ray - Complete Intraoral Series | $182 | 0% | $182 |
| X-Ray - Four Images, Bitewings | $66 | 0% | $66 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
| X-Ray - Whole Mouth from Outside Mouth | $161 | 0% | $161 |
