| Dental Cleaning - Adult | $216 | 0% | $216 |
| Dental Cleaning - Child | $185 | 0% | $185 |
| Dental Exam - Comprehensive | $181 | 0% | $181 |
| Dental Exam - Periodic, Established Patient | $99 | 0% | $99 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $683 | 0% | $683 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $410 | 0% | $410 |
| Dental Filling - White (Resin): One Surface, Anterior | $389 | 0% | $389 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $683 | 0% | $683 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $323 | 0% | $323 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $396 | 0% | $396 |
| Fluoride - Topical Application | $86 | 0% | $86 |
| Root Canal - Bicuspid Tooth | $2,016 | 0% | $2,016 |
| Root Canal - Molar | $2,415 | 0% | $2,415 |
| Tooth Extraction - Elevation and/or Forceps Removal | $399 | 0% | $399 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $61 | 0% | $61 |
| X-Ray - Complete Intraoral Series | $305 | 0% | $305 |
| X-Ray - Four Images, Bitewings | $160 | 0% | $160 |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | 0% | $46 |
