| Dental Cleaning - Adult | $114 | 0% | $114 |
| Dental Cleaning - Child | $81 | 0% | $81 |
| Dental Exam - Comprehensive | $97 | 0% | $97 |
| Dental Exam - Periodic, Established Patient | $56 | 0% | $56 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $205 | 0% | $205 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $324 | 0% | $324 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $261 | 0% | $261 |
| Dental Filling - White (Resin): One Surface, Anterior | $191 | 0% | $191 |
| Dental Filling - White (Resin): One Surface, Posterior | $205 | 0% | $205 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $324 | 0% | $324 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $232 | 0% | $232 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $261 | 0% | $261 |
| Flouride - Topical Varnish Application | $49 | 0% | $49 |
| Maintenance Therapy - Periodontal | $153 | 0% | $153 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $288 | 0% | $288 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $83 | 0% | $83 |
| Root Canal - Anterior Tooth | $843 | 0% | $843 |
| Root Canal - Bicuspid Tooth | $962 | 0% | $962 |
| Tooth Extraction - Elevation and/or Forceps Removal | $202 | 0% | $202 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
| X-Ray - Complete Intraoral Series | $224 | 0% | $224 |
| X-Ray - Four Images, Bitewings | $74 | 0% | $74 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $51 | 0% | $51 |
| X-Ray - Whole Mouth from Outside Mouth | $150 | 0% | $150 |
