| Dental Cleaning - Adult | $131 | 0% | $131 |
| Dental Cleaning - Child | $96 | 0% | $96 |
| Dental Exam - Comprehensive | $97 | 0% | $97 |
| Dental Exam - Periodic, Established Patient | $67 | 0% | $67 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $225 | 0% | $225 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $369 | 0% | $369 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $284 | 0% | $284 |
| Dental Filling - White (Resin): One Surface, Anterior | $384 | 0% | $384 |
| Dental Filling - White (Resin): One Surface, Posterior | $225 | 0% | $225 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $369 | 0% | $369 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $235 | 0% | $235 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $284 | 0% | $284 |
| Flouride - Topical Varnish Application | $88 | 0% | $88 |
| Maintenance Therapy - Periodontal | $233 | 0% | $233 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $330 | 0% | $330 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $131 | 0% | $131 |
| Root Canal - Anterior Tooth | $1,844 | 0% | $1,844 |
| Root Canal - Bicuspid Tooth | $1,137 | 0% | $1,137 |
| Root Canal - Molar | $2,717 | 0% | $2,717 |
| Tooth Extraction - Elevation and/or Forceps Removal | $244 | 0% | $244 |
| 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 | $88 | 0% | $88 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
| X-Ray - Two Images, Bitewings | $65 | 0% | $65 |
