| Dental Cleaning - Adult | $110 | 0% | $110 |
| Dental Cleaning - Child | $89 | 0% | $89 |
| Dental Exam - Comprehensive | $110 | 0% | $110 |
| Dental Exam - Periodic, Established Patient | $62 | 0% | $62 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $239 | 0% | $239 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $383 | 0% | $383 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $311 | 0% | $311 |
| Dental Filling - White (Resin): One Surface, Anterior | $230 | 0% | $230 |
| Dental Filling - White (Resin): One Surface, Posterior | $239 | 0% | $239 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $383 | 0% | $383 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $269 | 0% | $269 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $311 | 0% | $311 |
| Flouride - Topical Varnish Application | $41 | 0% | $41 |
| Fluoride - Topical Application | $54 | 0% | $54 |
| Maintenance Therapy - Periodontal | $179 | 0% | $179 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $107 | 0% | $107 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $337 | 0% | $337 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | 0% | $100 |
| Root Canal - Bicuspid Tooth | $1,121 | 0% | $1,121 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $68 | 0% | $68 |
| Tooth Extraction - Elevation and/or Forceps Removal | $252 | 0% | $252 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Complete Intraoral Series | $168 | 0% | $168 |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
| X-Ray - Two Images, Bitewings | $58 | 0% | $58 |
