| Dental Cleaning - Adult | $121 | 0% | $121 |
| Dental Cleaning - Child | $106 | 0% | $106 |
| Dental Exam - Comprehensive | $100 | 0% | $100 |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $212 | 0% | $212 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $318 | 0% | $318 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $277 | 0% | $277 |
| Dental Filling - White (Resin): One Surface, Anterior | $170 | 0% | $170 |
| Dental Filling - White (Resin): One Surface, Posterior | $212 | 0% | $212 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $318 | 0% | $318 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $217 | 0% | $217 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $277 | 0% | $277 |
| Flouride - Topical Varnish Application | $64 | 0% | $64 |
| Maintenance Therapy - Periodontal | $181 | 0% | $181 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $68 | 0% | $68 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $565 | 0% | $565 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $96 | 0% | $96 |
| Root Canal - Anterior Tooth | $1,479 | 0% | $1,479 |
| Root Canal - Bicuspid Tooth | $1,177 | 0% | $1,177 |
| Root Canal - Molar | $1,491 | 0% | $1,491 |
| Tooth Extraction - Elevation and/or Forceps Removal | $213 | 0% | $213 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | 0% | $33 |
| X-Ray - Complete Intraoral Series | $198 | 0% | $198 |
| X-Ray - Four Images, Bitewings | $77 | 0% | $77 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Whole Mouth from Outside Mouth | $292 | 0% | $292 |
