| Dental Cleaning - Child | $66 | 0% | $66 |
| Dental Exam - Periodic, Established Patient | $41 | 0% | $41 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $147 | 0% | $147 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $228 | 0% | $228 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $205 | 0% | $205 |
| Dental Filling - White (Resin): One Surface, Anterior | $168 | 0% | $168 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $260 | 0% | $260 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $194 | 0% | $194 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $205 | 0% | $205 |
| Root Canal - Anterior Tooth | $788 | 0% | $788 |
| Root Canal - Bicuspid Tooth | $998 | 0% | $998 |
| Root Canal - Molar | $1,103 | 0% | $1,103 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $48 | 0% | $48 |
| Tooth Extraction - Elevation and/or Forceps Removal | $168 | 0% | $168 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $22 | 0% | $22 |
| X-Ray - Complete Intraoral Series | $139 | 0% | $139 |
| X-Ray - Intraoral, Periapical Radiographic Image | $29 | 0% | $29 |
| X-Ray - Two Images, Bitewings | $41 | 0% | $41 |
| X-Ray - Whole Mouth from Outside Mouth | $109 | 0% | $109 |
