| Dental Cleaning - Adult | $131 | 0% | $131 |
| Dental Cleaning - Child | $116 | 0% | $116 |
| Dental Exam - Comprehensive | $89 | 0% | $89 |
| Dental Exam - Periodic, Established Patient | $56 | 0% | $56 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $184 | 0% | $184 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $194 | 0% | $194 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $205 | 0% | $205 |
| Dental Filling - White (Resin): One Surface, Anterior | $168 | 0% | $168 |
| Dental Filling - White (Resin): One Surface, Posterior | $184 | 0% | $184 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $452 | 0% | $452 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $399 | 0% | $399 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $205 | 0% | $205 |
| Fluoride - Topical Application | $39 | 0% | $39 |
| Maintenance Therapy - Periodontal | $179 | 0% | $179 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $79 | 0% | $79 |
| Root Canal - Anterior Tooth | $893 | 0% | $893 |
| Root Canal - Bicuspid Tooth | $1,654 | 0% | $1,654 |
| Root Canal - Molar | $1,365 | 0% | $1,365 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $221 | 0% | $221 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
| X-Ray - Complete Intraoral Series | $142 | 0% | $142 |
| X-Ray - Four Images, Bitewings | $68 | 0% | $68 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $48 | 0% | $48 |
| X-Ray - Whole Mouth from Outside Mouth | $252 | 0% | $252 |
