| Dental Cleaning - Adult | $116 | 0% | $116 |
| Dental Cleaning - Child | $101 | 0% | $101 |
| Dental Exam - Comprehensive | $103 | 0% | $103 |
| Dental Exam - Periodic, Established Patient | $56 | 0% | $56 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $203 | 0% | $203 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $365 | 0% | $365 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $293 | 0% | $293 |
| Dental Filling - White (Resin): One Surface, Anterior | $194 | 0% | $194 |
| Dental Filling - White (Resin): One Surface, Posterior | $234 | 0% | $234 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $365 | 0% | $365 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $234 | 0% | $234 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $305 | 0% | $305 |
| Flouride - Topical Varnish Application | $55 | 0% | $55 |
| Fluoride - Topical Application | $55 | 0% | $55 |
| Maintenance Therapy - Periodontal | $247 | 0% | $247 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $108 | 0% | $108 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $632 | 0% | $632 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | 0% | $100 |
| Root Canal - Anterior Tooth | $2,203 | 0% | $2,203 |
| Root Canal - Bicuspid Tooth | $1,827 | 0% | $1,827 |
| Root Canal - Molar | $1,323 | 0% | $1,323 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $251 | 0% | $251 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Complete Intraoral Series | $171 | 0% | $171 |
| X-Ray - Four Images, Bitewings | $80 | 0% | $80 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
| X-Ray - Two Images, Bitewings | $58 | 0% | $58 |
| X-Ray - Whole Mouth from Outside Mouth | $284 | 0% | $284 |
