| Dental Cleaning - Adult | $111 | 0% | $111 |
| Dental Cleaning - Child | $84 | 0% | $84 |
| Dental Exam - Periodic, Established Patient | $62 | 0% | $62 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $194 | 0% | $194 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $347 | 0% | $347 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | 0% | $263 |
| Dental Filling - White (Resin): One Surface, Posterior | $225 | 0% | $225 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $310 | 0% | $310 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $284 | 0% | $284 |
| Fluoride - Topical Application | $46 | 0% | $46 |
| Maintenance Therapy - Periodontal | $179 | 0% | $179 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $310 | 0% | $310 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | 0% | $105 |
| Root Canal - Bicuspid Tooth | $1,325 | 0% | $1,325 |
| Root Canal - Molar | $1,423 | 0% | $1,423 |
| Tooth Extraction - Elevation and/or Forceps Removal | $263 | 0% | $263 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | 0% | $38 |
| X-Ray - Complete Intraoral Series | $152 | 0% | $152 |
| X-Ray - Four Images, Bitewings | $80 | 0% | $80 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
| X-Ray - Two Images, Bitewings | $80 | 0% | $80 |
| X-Ray - Whole Mouth from Outside Mouth | $154 | 0% | $154 |
