| Dental Cleaning - Adult | $126 | 0% | $126 |
| Dental Cleaning - Child | $179 | 0% | $179 |
| Dental Exam - Comprehensive | $189 | 0% | $189 |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $236 | 0% | $236 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $347 | 0% | $347 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $284 | 0% | $284 |
| Dental Filling - White (Resin): One Surface, Anterior | $205 | 0% | $205 |
| Dental Filling - White (Resin): One Surface, Posterior | $236 | 0% | $236 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $231 | 0% | $231 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $284 | 0% | $284 |
| Flouride - Topical Varnish Application | $48 | 0% | $48 |
| Maintenance Therapy - Periodontal | $162 | 0% | $162 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $134 | 0% | $134 |
| Root Canal - Anterior Tooth | $893 | 0% | $893 |
| Tooth Extraction - Elevation and/or Forceps Removal | $231 | 0% | $231 |
| X-Ray - Complete Intraoral Series | $227 | 0% | $227 |
| X-Ray - Four Images, Bitewings | $80 | 0% | $80 |
| X-Ray - Intraoral, Periapical Radiographic Image | $74 | 0% | $74 |
| X-Ray - Two Images, Bitewings | $87 | 0% | $87 |
