| Dental Cleaning - Adult | $113 | 0% | $113 |
| Dental Cleaning - Child | $120 | 0% | $120 |
| Dental Exam - Comprehensive | $100 | 0% | $100 |
| Dental Exam - Periodic, Established Patient | $74 | 0% | $74 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $205 | 0% | $205 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | 0% | $326 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | 0% | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $189 | 0% | $189 |
| 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 | $251 | 0% | $251 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $268 | 0% | $268 |
| Flouride - Topical Varnish Application | $50 | 0% | $50 |
| Maintenance Therapy - Periodontal | $212 | 0% | $212 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | 0% | $101 |
| Root Canal - Anterior Tooth | $1,187 | 0% | $1,187 |
| Root Canal - Bicuspid Tooth | $1,541 | 0% | $1,541 |
| Root Canal - Molar | $1,614 | 0% | $1,614 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $65 | 0% | $65 |
| Tooth Extraction - Elevation and/or Forceps Removal | $226 | 0% | $226 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
| X-Ray - Complete Intraoral Series | $218 | 0% | $218 |
| X-Ray - Four Images, Bitewings | $89 | 0% | $89 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
| X-Ray - Two Images, Bitewings | $61 | 0% | $61 |
| X-Ray - Whole Mouth from Outside Mouth | $142 | 0% | $142 |
