| Dental Cleaning - Adult | $116 | 0% | $116 |
| Dental Cleaning - Child | $93 | 0% | $93 |
| Dental Exam - Comprehensive | $108 | 0% | $108 |
| Dental Exam - Periodic, Established Patient | $62 | 0% | $62 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $219 | 0% | $219 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $379 | 0% | $379 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $292 | 0% | $292 |
| Dental Filling - White (Resin): One Surface, Anterior | $200 | 0% | $200 |
| Dental Filling - White (Resin): One Surface, Posterior | $219 | 0% | $219 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $379 | 0% | $379 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $249 | 0% | $249 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $292 | 0% | $292 |
| Flouride - Topical Varnish Application | $45 | 0% | $45 |
| Maintenance Therapy - Periodontal | $163 | 0% | $163 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $316 | 0% | $316 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $98 | 0% | $98 |
| Root Canal - Anterior Tooth | $1,066 | 0% | $1,066 |
| Root Canal - Bicuspid Tooth | $1,315 | 0% | $1,315 |
| Root Canal - Molar | $1,503 | 0% | $1,503 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $64 | 0% | $64 |
| Tooth Extraction - Elevation and/or Forceps Removal | $225 | 0% | $225 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | 0% | $30 |
| X-Ray - Complete Intraoral Series | $163 | 0% | $163 |
| X-Ray - Four Images, Bitewings | $81 | 0% | $81 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $56 | 0% | $56 |
| X-Ray - Whole Mouth from Outside Mouth | $143 | 0% | $143 |
