| Dental Cleaning - Adult | $144 | 0% | $144 |
| Dental Cleaning - Child | $79 | 0% | $79 |
| Dental Exam - Comprehensive | $168 | 0% | $168 |
| Dental Exam - Periodic, Established Patient | $64 | 0% | $64 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $303 | 0% | $303 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $389 | 0% | $389 |
| Dental Filling - White (Resin): One Surface, Posterior | $303 | 0% | $303 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $460 | 0% | $460 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $303 | 0% | $303 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $389 | 0% | $389 |
| Flouride - Topical Varnish Application | $70 | 0% | $70 |
| Maintenance Therapy - Periodontal | $225 | 0% | $225 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $121 | 0% | $121 |
| Root Canal - Anterior Tooth | $1,212 | 0% | $1,212 |
| Root Canal - Bicuspid Tooth | $1,265 | 0% | $1,265 |
| Root Canal - Molar | $1,544 | 0% | $1,544 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | 0% | $69 |
| Tooth Extraction - Elevation and/or Forceps Removal | $313 | 0% | $313 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
| X-Ray - Complete Intraoral Series | $194 | 0% | $194 |
| X-Ray - Four Images, Bitewings | $102 | 0% | $102 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
| X-Ray - Two Images, Bitewings | $74 | 0% | $74 |
| X-Ray - Whole Mouth from Outside Mouth | $305 | 0% | $305 |
