| Dental Cleaning - Child | $68 | 0% | $68 |
| Dental Exam - Comprehensive | $89 | 0% | $89 |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $145 | 0% | $145 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $210 | 0% | $210 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $179 | 0% | $179 |
| Dental Filling - White (Resin): One Surface, Anterior | $163 | 0% | $163 |
| Dental Filling - White (Resin): One Surface, Posterior | $184 | 0% | $184 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $289 | 0% | $289 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $194 | 0% | $194 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $236 | 0% | $236 |
| Fluoride - Topical Application | $32 | 0% | $32 |
| Maintenance Therapy - Periodontal | $131 | 0% | $131 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $236 | 0% | $236 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $79 | 0% | $79 |
| Root Canal - Anterior Tooth | $840 | 0% | $840 |
| Root Canal - Bicuspid Tooth | $945 | 0% | $945 |
| Root Canal - Molar | $1,208 | 0% | $1,208 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $47 | 0% | $47 |
| Tooth Extraction - Elevation and/or Forceps Removal | $184 | 0% | $184 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $16 | 0% | $16 |
| X-Ray - Complete Intraoral Series | $142 | 0% | $142 |
| X-Ray - Four Images, Bitewings | $63 | 0% | $63 |
| X-Ray - Intraoral, Periapical Radiographic Image | $32 | 0% | $32 |
| X-Ray - Two Images, Bitewings | $47 | 0% | $47 |
| X-Ray - Whole Mouth from Outside Mouth | $126 | 0% | $126 |
