| Dental Cleaning - Adult | $114 | 0% | $114 |
| Dental Cleaning - Child | $86 | 0% | $86 |
| Dental Exam - Comprehensive | $103 | 0% | $103 |
| Dental Exam - Periodic, Established Patient | $61 | 0% | $61 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $203 | 0% | $203 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $385 | 0% | $385 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $272 | 0% | $272 |
| Dental Filling - White (Resin): One Surface, Anterior | $185 | 0% | $185 |
| Dental Filling - White (Resin): One Surface, Posterior | $203 | 0% | $203 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $332 | 0% | $332 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $226 | 0% | $226 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $272 | 0% | $272 |
| Flouride - Topical Varnish Application | $45 | 0% | $45 |
| Fluoride - Topical Application | $45 | 0% | $45 |
| Maintenance Therapy - Periodontal | $159 | 0% | $159 |
| 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 | $89 | 0% | $89 |
| Root Canal - Anterior Tooth | $735 | 0% | $735 |
| Root Canal - Bicuspid Tooth | $1,021 | 0% | $1,021 |
| Root Canal - Molar | $1,647 | 0% | $1,647 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | 0% | $60 |
| Tooth Extraction - Elevation and/or Forceps Removal | $215 | 0% | $215 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
| X-Ray - Complete Intraoral Series | $156 | 0% | $156 |
| X-Ray - Four Images, Bitewings | $72 | 0% | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $58 | 0% | $58 |
| X-Ray - Whole Mouth from Outside Mouth | $153 | 0% | $153 |
