| Dental Cleaning - Adult | $128 | 0% | $128 |
| Dental Cleaning - Child | $102 | 0% | $102 |
| Dental Exam - Comprehensive | $110 | 0% | $110 |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $233 | 0% | $233 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $435 | 0% | $435 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $313 | 0% | $313 |
| Dental Filling - White (Resin): One Surface, Anterior | $229 | 0% | $229 |
| Dental Filling - White (Resin): One Surface, Posterior | $233 | 0% | $233 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $435 | 0% | $435 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | 0% | $271 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $313 | 0% | $313 |
| Flouride - Topical Varnish Application | $57 | 0% | $57 |
| Fluoride - Topical Application | $54 | 0% | $54 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | 0% | $105 |
| Root Canal - Anterior Tooth | $1,032 | 0% | $1,032 |
| Root Canal - Bicuspid Tooth | $1,168 | 0% | $1,168 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $73 | 0% | $73 |
| Tooth Extraction - Elevation and/or Forceps Removal | $236 | 0% | $236 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | 0% | $36 |
| X-Ray - Complete Intraoral Series | $193 | 0% | $193 |
| X-Ray - Four Images, Bitewings | $91 | 0% | $91 |
| X-Ray - Intraoral, Periapical Radiographic Image | $44 | 0% | $44 |
| X-Ray - Two Images, Bitewings | $66 | 0% | $66 |
| X-Ray - Whole Mouth from Outside Mouth | $169 | 0% | $169 |
