| Dental Cleaning - Adult | $110 | 0% | $110 |
| Dental Cleaning - Child | $110 | 0% | $110 |
| Dental Exam - Comprehensive | $105 | 0% | $105 |
| Dental Exam - Periodic, Established Patient | $61 | 0% | $61 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | 0% | $208 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | 0% | $326 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | 0% | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $212 | 0% | $212 |
| Dental Filling - White (Resin): One Surface, Posterior | $219 | 0% | $219 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $343 | 0% | $343 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | 0% | $271 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $321 | 0% | $321 |
| Flouride - Topical Varnish Application | $56 | 0% | $56 |
| Fluoride - Topical Application | $51 | 0% | $51 |
| Maintenance Therapy - Periodontal | $146 | 0% | $146 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $99 | 0% | $99 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $251 | 0% | $251 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
| Root Canal - Anterior Tooth | $887 | 0% | $887 |
| Root Canal - Bicuspid Tooth | $940 | 0% | $940 |
| Root Canal - Molar | $1,045 | 0% | $1,045 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | 0% | $71 |
| Tooth Extraction - Elevation and/or Forceps Removal | $168 | 0% | $168 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $25 | 0% | $25 |
| X-Ray - Complete Intraoral Series | $160 | 0% | $160 |
| X-Ray - Four Images, Bitewings | $80 | 0% | $80 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | 0% | $36 |
| X-Ray - Two Images, Bitewings | $76 | 0% | $76 |
| X-Ray - Whole Mouth from Outside Mouth | $135 | 0% | $135 |
