| Dental Cleaning - Adult | $123 | 0% | $123 |
| Dental Cleaning - Child | $86 | 0% | $86 |
| Dental Exam - Comprehensive | $138 | 0% | $138 |
| Dental Exam - Periodic, Established Patient | $55 | 0% | $55 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $215 | 0% | $215 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $383 | 0% | $383 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $302 | 0% | $302 |
| Dental Filling - White (Resin): One Surface, Anterior | $189 | 0% | $189 |
| Dental Filling - White (Resin): One Surface, Posterior | $215 | 0% | $215 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $383 | 0% | $383 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $245 | 0% | $245 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $302 | 0% | $302 |
| Flouride - Topical Varnish Application | $53 | 0% | $53 |
| Maintenance Therapy - Periodontal | $162 | 0% | $162 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $46 | 0% | $46 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $291 | 0% | $291 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | 0% | $105 |
| Root Canal - Anterior Tooth | $947 | 0% | $947 |
| Root Canal - Bicuspid Tooth | $1,082 | 0% | $1,082 |
| Root Canal - Molar | $1,308 | 0% | $1,308 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | 0% | $69 |
| Tooth Extraction - Elevation and/or Forceps Removal | $203 | 0% | $203 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
| X-Ray - Complete Intraoral Series | $168 | 0% | $168 |
| X-Ray - Four Images, Bitewings | $81 | 0% | $81 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $57 | 0% | $57 |
| X-Ray - Whole Mouth from Outside Mouth | $162 | 0% | $162 |
