| Dental Cleaning - Adult | $110 | 0% | $110 |
| Dental Cleaning - Child | $81 | 0% | $81 |
| Dental Exam - Comprehensive | $102 | 0% | $102 |
| Dental Exam - Periodic, Established Patient | $64 | 0% | $64 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $202 | 0% | $202 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $340 | 0% | $340 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $261 | 0% | $261 |
| Dental Filling - White (Resin): One Surface, Anterior | $187 | 0% | $187 |
| Dental Filling - White (Resin): One Surface, Posterior | $202 | 0% | $202 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $340 | 0% | $340 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $229 | 0% | $229 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $261 | 0% | $261 |
| Flouride - Topical Varnish Application | $49 | 0% | $49 |
| Fluoride - Topical Application | $43 | 0% | $43 |
| Maintenance Therapy - Periodontal | $151 | 0% | $151 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $91 | 0% | $91 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $285 | 0% | $285 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
| Root Canal - Anterior Tooth | $919 | 0% | $919 |
| Root Canal - Bicuspid Tooth | $1,024 | 0% | $1,024 |
| Root Canal - Molar | $1,231 | 0% | $1,231 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $155 | 0% | $155 |
| X-Ray - Complete Intraoral Series | $153 | 0% | $153 |
| X-Ray - Four Images, Bitewings | $75 | 0% | $75 |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
| X-Ray - Whole Mouth from Outside Mouth | $132 | 0% | $132 |
