| Dental Cleaning - Adult | $129 | 0% | $129 |
| Dental Cleaning - Child | $96 | 0% | $96 |
| Dental Exam - Comprehensive | $126 | 0% | $126 |
| Dental Exam - Periodic, Established Patient | $79 | 0% | $79 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $240 | 0% | $240 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $383 | 0% | $383 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $305 | 0% | $305 |
| Dental Filling - White (Resin): One Surface, Anterior | $225 | 0% | $225 |
| Dental Filling - White (Resin): One Surface, Posterior | $240 | 0% | $240 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $383 | 0% | $383 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $272 | 0% | $272 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $305 | 0% | $305 |
| Flouride - Topical Varnish Application | $58 | 0% | $58 |
| Fluoride - Topical Application | $45 | 0% | $45 |
| Maintenance Therapy - Periodontal | $188 | 0% | $188 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $60 | 0% | $60 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $329 | 0% | $329 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | 0% | $105 |
| Root Canal - Anterior Tooth | $929 | 0% | $929 |
| Root Canal - Bicuspid Tooth | $1,071 | 0% | $1,071 |
| Root Canal - Molar | $2,040 | 0% | $2,040 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | 0% | $68 |
| Tooth Extraction - Elevation and/or Forceps Removal | $250 | 0% | $250 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
| X-Ray - Complete Intraoral Series | $210 | 0% | $210 |
| X-Ray - Four Images, Bitewings | $96 | 0% | $96 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
| X-Ray - Whole Mouth from Outside Mouth | $163 | 0% | $163 |
