| Dental Cleaning - Adult | $113 | 0% | $113 |
| Dental Cleaning - Child | $118 | 0% | $118 |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $185 | 0% | $185 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $331 | 0% | $331 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $245 | 0% | $245 |
| Dental Filling - White (Resin): One Surface, Anterior | $176 | 0% | $176 |
| Dental Filling - White (Resin): One Surface, Posterior | $210 | 0% | $210 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $370 | 0% | $370 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $269 | 0% | $269 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $300 | 0% | $300 |
| Flouride - Topical Varnish Application | $58 | 0% | $58 |
| Maintenance Therapy - Periodontal | $193 | 0% | $193 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | 0% | $101 |
| Root Canal - Bicuspid Tooth | $1,238 | 0% | $1,238 |
| Root Canal - Molar | $1,758 | 0% | $1,758 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $67 | 0% | $67 |
| Tooth Extraction - Elevation and/or Forceps Removal | $239 | 0% | $239 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
| X-Ray - Complete Intraoral Series | $197 | 0% | $197 |
| X-Ray - Four Images, Bitewings | $110 | 0% | $110 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
| X-Ray - Whole Mouth from Outside Mouth | $170 | 0% | $170 |
