| Dental Cleaning - Adult | $112 | 0% | $112 |
| Dental Cleaning - Child | $90 | 0% | $90 |
| Dental Exam - Comprehensive | $104 | 0% | $104 |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $216 | 0% | $216 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $372 | 0% | $372 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $286 | 0% | $286 |
| Dental Filling - White (Resin): One Surface, Anterior | $206 | 0% | $206 |
| Dental Filling - White (Resin): One Surface, Posterior | $216 | 0% | $216 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $372 | 0% | $372 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $255 | 0% | $255 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $286 | 0% | $286 |
| Flouride - Topical Varnish Application | $45 | 0% | $45 |
| Fluoride - Topical Application | $45 | 0% | $45 |
| Maintenance Therapy - Periodontal | $161 | 0% | $161 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $112 | 0% | $112 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $331 | 0% | $331 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $93 | 0% | $93 |
| Root Canal - Anterior Tooth | $921 | 0% | $921 |
| Root Canal - Bicuspid Tooth | $1,028 | 0% | $1,028 |
| Root Canal - Molar | $1,280 | 0% | $1,280 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $62 | 0% | $62 |
| Tooth Extraction - Elevation and/or Forceps Removal | $215 | 0% | $215 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
| X-Ray - Complete Intraoral Series | $182 | 0% | $182 |
| X-Ray - Four Images, Bitewings | $82 | 0% | $82 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
| X-Ray - Two Images, Bitewings | $60 | 0% | $60 |
| X-Ray - Whole Mouth from Outside Mouth | $138 | 0% | $138 |
