| Dental Cleaning - Adult | $107 | 0% | $107 |
| Dental Cleaning - Child | $120 | 0% | $120 |
| Dental Exam - Comprehensive | $120 | 0% | $120 |
| Dental Exam - Periodic, Established Patient | $74 | 0% | $74 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | 0% | $208 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | 0% | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $273 | 0% | $273 |
| Dental Filling - White (Resin): One Surface, Anterior | $183 | 0% | $183 |
| Dental Filling - White (Resin): One Surface, Posterior | $233 | 0% | $233 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $391 | 0% | $391 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $229 | 0% | $229 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $321 | 0% | $321 |
| Flouride - Topical Varnish Application | $53 | 0% | $53 |
| Maintenance Therapy - Periodontal | $212 | 0% | $212 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $269 | 0% | $269 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $86 | 0% | $86 |
| Root Canal - Anterior Tooth | $806 | 0% | $806 |
| Root Canal - Bicuspid Tooth | $945 | 0% | $945 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $80 | 0% | $80 |
| Tooth Extraction - Elevation and/or Forceps Removal | $260 | 0% | $260 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
| X-Ray - Complete Intraoral Series | $147 | 0% | $147 |
| X-Ray - Four Images, Bitewings | $95 | 0% | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $53 | 0% | $53 |
| X-Ray - Whole Mouth from Outside Mouth | $185 | 0% | $185 |
