| Dental Cleaning - Adult | $105 | 0% | $105 |
| Dental Cleaning - Child | $93 | 0% | $93 |
| Dental Exam - Comprehensive | $102 | 0% | $102 |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | 0% | $189 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | 0% | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $286 | 0% | $286 |
| Dental Filling - White (Resin): One Surface, Anterior | $165 | 0% | $165 |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | 0% | $189 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | 0% | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $243 | 0% | $243 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $286 | 0% | $286 |
| Flouride - Topical Varnish Application | $46 | 0% | $46 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $97 | 0% | $97 |
| Root Canal - Bicuspid Tooth | $979 | 0% | $979 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $67 | 0% | $67 |
| Tooth Extraction - Elevation and/or Forceps Removal | $207 | 0% | $207 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
| X-Ray - Complete Intraoral Series | $163 | 0% | $163 |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $60 | 0% | $60 |
| X-Ray - Whole Mouth from Outside Mouth | $138 | 0% | $138 |
