| Dental Cleaning - Adult | $99 | 0% | $99 |
| Dental Cleaning - Child | $79 | 0% | $79 |
| Dental Exam - Comprehensive | $95 | 0% | $95 |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | 0% | $189 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $299 | 0% | $299 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $236 | 0% | $236 |
| Dental Filling - White (Resin): One Surface, Anterior | $160 | 0% | $160 |
| Dental Filling - White (Resin): One Surface, Posterior | $168 | 0% | $168 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $299 | 0% | $299 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $195 | 0% | $195 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $236 | 0% | $236 |
| Fluoride - Topical Application | $39 | 0% | $39 |
| Maintenance Therapy - Periodontal | $153 | 0% | $153 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $89 | 0% | $89 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $239 | 0% | $239 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $79 | 0% | $79 |
| Root Canal - Anterior Tooth | $877 | 0% | $877 |
| Root Canal - Bicuspid Tooth | $971 | 0% | $971 |
| Root Canal - Molar | $1,208 | 0% | $1,208 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | 0% | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $221 | 0% | $221 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
| X-Ray - Complete Intraoral Series | $147 | 0% | $147 |
| X-Ray - Four Images, Bitewings | $69 | 0% | $69 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $46 | 0% | $46 |
| X-Ray - Whole Mouth from Outside Mouth | $152 | 0% | $152 |
