| Dental Cleaning - Adult | $121 | 0% | $121 |
| Dental Cleaning - Child | $85 | 0% | $85 |
| Dental Exam - Comprehensive | $147 | 0% | $147 |
| Dental Exam - Periodic, Established Patient | $59 | 0% | $59 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $210 | 0% | $210 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $315 | 0% | $315 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $252 | 0% | $252 |
| Dental Filling - White (Resin): One Surface, Anterior | $231 | 0% | $231 |
| Dental Filling - White (Resin): One Surface, Posterior | $247 | 0% | $247 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $289 | 0% | $289 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $315 | 0% | $315 |
| Flouride - Topical Varnish Application | $58 | 0% | $58 |
| Maintenance Therapy - Periodontal | $163 | 0% | $163 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $126 | 0% | $126 |
| Root Canal - Bicuspid Tooth | $1,155 | 0% | $1,155 |
| Root Canal - Molar | $1,355 | 0% | $1,355 |
| Tooth Extraction - Elevation and/or Forceps Removal | $236 | 0% | $236 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $26 | 0% | $26 |
| X-Ray - Complete Intraoral Series | $242 | 0% | $242 |
| X-Ray - Four Images, Bitewings | $89 | 0% | $89 |
| X-Ray - Intraoral, Periapical Radiographic Image | $41 | 0% | $41 |
| X-Ray - Two Images, Bitewings | $109 | 0% | $109 |
| X-Ray - Whole Mouth from Outside Mouth | $147 | 0% | $147 |
