| Dental Cleaning - Adult | $133 | 0% | $133 |
| Dental Cleaning - Child | $104 | 0% | $104 |
| Dental Exam - Comprehensive | $109 | 0% | $109 |
| Dental Exam - Periodic, Established Patient | $59 | 0% | $59 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $232 | 0% | $232 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $316 | 0% | $316 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $221 | 0% | $221 |
| Dental Filling - White (Resin): One Surface, Anterior | $201 | 0% | $201 |
| Dental Filling - White (Resin): One Surface, Posterior | $232 | 0% | $232 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $389 | 0% | $389 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $240 | 0% | $240 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $302 | 0% | $302 |
| Flouride - Topical Varnish Application | $47 | 0% | $47 |
| Fluoride - Topical Application | $48 | 0% | $48 |
| Maintenance Therapy - Periodontal | $180 | 0% | $180 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $93 | 0% | $93 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $328 | 0% | $328 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | 0% | $100 |
| Root Canal - Anterior Tooth | $1,215 | 0% | $1,215 |
| Root Canal - Bicuspid Tooth | $1,489 | 0% | $1,489 |
| Root Canal - Molar | $1,691 | 0% | $1,691 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | 0% | $71 |
| Tooth Extraction - Elevation and/or Forceps Removal | $216 | 0% | $216 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
| X-Ray - Complete Intraoral Series | $177 | 0% | $177 |
| X-Ray - Four Images, Bitewings | $85 | 0% | $85 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $59 | 0% | $59 |
| X-Ray - Whole Mouth from Outside Mouth | $155 | 0% | $155 |
