| Dental Cleaning - Adult | $128 | 0% | $128 |
| Dental Cleaning - Child | $120 | 0% | $120 |
| Dental Exam - Comprehensive | $105 | 0% | $105 |
| Dental Exam - Periodic, Established Patient | $61 | 0% | $61 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $229 | 0% | $229 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $565 | 0% | $565 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $288 | 0% | $288 |
| Dental Filling - White (Resin): One Surface, Anterior | $212 | 0% | $212 |
| Dental Filling - White (Resin): One Surface, Posterior | $229 | 0% | $229 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $391 | 0% | $391 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $243 | 0% | $243 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $288 | 0% | $288 |
| Flouride - Topical Varnish Application | $71 | 0% | $71 |
| Fluoride - Topical Application | $69 | 0% | $69 |
| Maintenance Therapy - Periodontal | $212 | 0% | $212 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $143 | 0% | $143 |
| 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 | $108 | 0% | $108 |
| Root Canal - Anterior Tooth | $1,399 | 0% | $1,399 |
| Root Canal - Bicuspid Tooth | $1,638 | 0% | $1,638 |
| Root Canal - Molar | $1,563 | 0% | $1,563 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $66 | 0% | $66 |
| Tooth Extraction - Elevation and/or Forceps Removal | $211 | 0% | $211 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $11 | 0% | $11 |
| X-Ray - Complete Intraoral Series | $175 | 0% | $175 |
| X-Ray - Four Images, Bitewings | $89 | 0% | $89 |
| X-Ray - Intraoral, Periapical Radiographic Image | $47 | 0% | $47 |
| X-Ray - Two Images, Bitewings | $76 | 0% | $76 |
| X-Ray - Whole Mouth from Outside Mouth | $185 | 0% | $185 |
