| Dental Cleaning - Adult | $104 | 0% | $104 |
| Dental Cleaning - Child | $83 | 0% | $83 |
| Dental Exam - Comprehensive | $89 | 0% | $89 |
| Dental Exam - Periodic, Established Patient | $51 | 0% | $51 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $194 | 0% | $194 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $303 | 0% | $303 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $261 | 0% | $261 |
| Dental Filling - White (Resin): One Surface, Anterior | $163 | 0% | $163 |
| Dental Filling - White (Resin): One Surface, Posterior | $186 | 0% | $186 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $303 | 0% | $303 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $198 | 0% | $198 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $261 | 0% | $261 |
| Flouride - Topical Varnish Application | $41 | 0% | $41 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $263 | 0% | $263 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $72 | 0% | $72 |
| Root Canal - Anterior Tooth | $814 | 0% | $814 |
| Root Canal - Bicuspid Tooth | $1,410 | 0% | $1,410 |
| Root Canal - Molar | $1,045 | 0% | $1,045 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $177 | 0% | $177 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
| X-Ray - Complete Intraoral Series | $154 | 0% | $154 |
| X-Ray - Four Images, Bitewings | $72 | 0% | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
| X-Ray - Two Images, Bitewings | $49 | 0% | $49 |
