| Dental Cleaning - Adult | $141 | 0% | $141 |
| Dental Cleaning - Child | $110 | 0% | $110 |
| Dental Exam - Periodic, Established Patient | $72 | 0% | $72 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $295 | 0% | $295 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $360 | 0% | $360 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $369 | 0% | $369 |
| Dental Filling - White (Resin): One Surface, Anterior | $277 | 0% | $277 |
| Dental Filling - White (Resin): One Surface, Posterior | $295 | 0% | $295 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $419 | 0% | $419 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $234 | 0% | $234 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $352 | 0% | $352 |
| Flouride - Topical Varnish Application | $56 | 0% | $56 |
| Maintenance Therapy - Periodontal | $188 | 0% | $188 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $107 | 0% | $107 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $392 | 0% | $392 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $116 | 0% | $116 |
| Root Canal - Anterior Tooth | $1,103 | 0% | $1,103 |
| Tooth Extraction - Elevation and/or Forceps Removal | $358 | 0% | $358 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $50 | 0% | $50 |
| X-Ray - Complete Intraoral Series | $225 | 0% | $225 |
| X-Ray - Four Images, Bitewings | $114 | 0% | $114 |
| X-Ray - Intraoral, Periapical Radiographic Image | $50 | 0% | $50 |
| X-Ray - Two Images, Bitewings | $95 | 0% | $95 |
| X-Ray - Whole Mouth from Outside Mouth | $225 | 0% | $225 |
