| Dental Cleaning - Adult | $111 | 0% | $111 |
| Dental Cleaning - Child | $120 | 0% | $120 |
| Dental Exam - Comprehensive | $116 | 0% | $116 |
| Dental Exam - Periodic, Established Patient | $50 | 0% | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $177 | 0% | $177 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | 0% | $326 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $245 | 0% | $245 |
| Dental Filling - White (Resin): One Surface, Anterior | $164 | 0% | $164 |
| Dental Filling - White (Resin): One Surface, Posterior | $177 | 0% | $177 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $299 | 0% | $299 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | 0% | $271 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $321 | 0% | $321 |
| Flouride - Topical Varnish Application | $39 | 0% | $39 |
| Maintenance Therapy - Periodontal | $212 | 0% | $212 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $105 | 0% | $105 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $395 | 0% | $395 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $86 | 0% | $86 |
| Root Canal - Anterior Tooth | $1,072 | 0% | $1,072 |
| Root Canal - Bicuspid Tooth | $952 | 0% | $952 |
| Root Canal - Molar | $1,176 | 0% | $1,176 |
| Tooth Extraction - Elevation and/or Forceps Removal | $260 | 0% | $260 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $17 | 0% | $17 |
| X-Ray - Complete Intraoral Series | $214 | 0% | $214 |
| X-Ray - Four Images, Bitewings | $86 | 0% | $86 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $76 | 0% | $76 |
| X-Ray - Whole Mouth from Outside Mouth | $132 | 0% | $132 |
