| Dental Cleaning - Adult | $118 | 0% | $118 |
| Dental Cleaning - Child | $80 | 0% | $80 |
| Dental Exam - Comprehensive | $110 | 0% | $110 |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $237 | 0% | $237 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $360 | 0% | $360 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $286 | 0% | $286 |
| Dental Filling - White (Resin): One Surface, Anterior | $221 | 0% | $221 |
| Dental Filling - White (Resin): One Surface, Posterior | $237 | 0% | $237 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $439 | 0% | $439 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $254 | 0% | $254 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $286 | 0% | $286 |
| Fluoride - Topical Application | $48 | 0% | $48 |
| Maintenance Therapy - Periodontal | $154 | 0% | $154 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $79 | 0% | $79 |
| Root Canal - Bicuspid Tooth | $924 | 0% | $924 |
| Root Canal - Molar | $2,205 | 0% | $2,205 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | 0% | $60 |
| Tooth Extraction - Elevation and/or Forceps Removal | $284 | 0% | $284 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $63 | 0% | $63 |
| X-Ray - Complete Intraoral Series | $168 | 0% | $168 |
| X-Ray - Four Images, Bitewings | $79 | 0% | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
| X-Ray - Two Images, Bitewings | $109 | 0% | $109 |
| X-Ray - Whole Mouth from Outside Mouth | $142 | 0% | $142 |
