| Dental Cleaning - Adult | $168 | 0% | $168 |
| Dental Cleaning - Child | $95 | 0% | $95 |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $173 | 0% | $173 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $299 | 0% | $299 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $168 | 0% | $168 |
| Dental Filling - White (Resin): One Surface, Anterior | $147 | 0% | $147 |
| Dental Filling - White (Resin): One Surface, Posterior | $173 | 0% | $173 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $200 | 0% | $200 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $431 | 0% | $431 |
| Fluoride - Topical Application | $42 | 0% | $42 |
| Maintenance Therapy - Periodontal | $284 | 0% | $284 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $158 | 0% | $158 |
| Root Canal - Molar | $2,730 | 0% | $2,730 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $116 | 0% | $116 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $21 | 0% | $21 |
| X-Ray - Complete Intraoral Series | $197 | 0% | $197 |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
