| Dental Cleaning - Adult | $87 | 0% | $87 |
| Dental Cleaning - Child | $70 | 0% | $70 |
| Dental Exam - Comprehensive | $77 | 0% | $77 |
| Dental Exam - Periodic, Established Patient | $42 | 0% | $42 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $125 | 0% | $125 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $282 | 0% | $282 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $217 | 0% | $217 |
| Dental Filling - White (Resin): One Surface, Anterior | $140 | 0% | $140 |
| Dental Filling - White (Resin): One Surface, Posterior | $155 | 0% | $155 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $171 | 0% | $171 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $217 | 0% | $217 |
| Flouride - Topical Varnish Application | $36 | 0% | $36 |
| Fluoride - Topical Application | $37 | 0% | $37 |
| Maintenance Therapy - Periodontal | $128 | 0% | $128 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $231 | 0% | $231 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $74 | 0% | $74 |
| Root Canal - Anterior Tooth | $735 | 0% | $735 |
| Root Canal - Bicuspid Tooth | $820 | 0% | $820 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $48 | 0% | $48 |
| Tooth Extraction - Elevation and/or Forceps Removal | $155 | 0% | $155 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $24 | 0% | $24 |
| X-Ray - Complete Intraoral Series | $125 | 0% | $125 |
| X-Ray - Four Images, Bitewings | $60 | 0% | $60 |
| X-Ray - Intraoral, Periapical Radiographic Image | $28 | 0% | $28 |
| X-Ray - Two Images, Bitewings | $47 | 0% | $47 |
