| Dental Cleaning - Adult | $119 | 0% | $119 |
| Dental Cleaning - Child | $120 | 0% | $120 |
| Dental Exam - Comprehensive | $120 | 0% | $120 |
| Dental Exam - Periodic, Established Patient | $69 | 0% | $69 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $219 | 0% | $219 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | 0% | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $280 | 0% | $280 |
| Dental Filling - White (Resin): One Surface, Anterior | $205 | 0% | $205 |
| Dental Filling - White (Resin): One Surface, Posterior | $233 | 0% | $233 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | 0% | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $249 | 0% | $249 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $280 | 0% | $280 |
| Fluoride - Topical Application | $47 | 0% | $47 |
| Maintenance Therapy - Periodontal | $173 | 0% | $173 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $30 | 0% | $30 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $303 | 0% | $303 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
| Root Canal - Anterior Tooth | $877 | 0% | $877 |
| Root Canal - Bicuspid Tooth | $1,541 | 0% | $1,541 |
| Root Canal - Molar | $1,785 | 0% | $1,785 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $80 | 0% | $80 |
| Tooth Extraction - Elevation and/or Forceps Removal | $260 | 0% | $260 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
| X-Ray - Complete Intraoral Series | $188 | 0% | $188 |
| X-Ray - Four Images, Bitewings | $76 | 0% | $76 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $76 | 0% | $76 |
| X-Ray - Whole Mouth from Outside Mouth | $137 | 0% | $137 |
