| Dental Cleaning - Adult | $108 | 0% | $108 |
| Dental Cleaning - Child | $86 | 0% | $86 |
| Dental Exam - Comprehensive | $104 | 0% | $104 |
| Dental Exam - Periodic, Established Patient | $55 | 0% | $55 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $171 | 0% | $171 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $266 | 0% | $266 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $214 | 0% | $214 |
| Dental Filling - White (Resin): One Surface, Anterior | $200 | 0% | $200 |
| Dental Filling - White (Resin): One Surface, Posterior | $219 | 0% | $219 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $344 | 0% | $344 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $242 | 0% | $242 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $275 | 0% | $275 |
| Flouride - Topical Varnish Application | $45 | 0% | $45 |
| Maintenance Therapy - Periodontal | $311 | 0% | $311 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $91 | 0% | $91 |
| Root Canal - Molar | $1,219 | 0% | $1,219 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $66 | 0% | $66 |
| Tooth Extraction - Elevation and/or Forceps Removal | $214 | 0% | $214 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Complete Intraoral Series | $155 | 0% | $155 |
| X-Ray - Four Images, Bitewings | $78 | 0% | $78 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $57 | 0% | $57 |
