| Dental Cleaning - Adult | $131 | 0% | $131 |
| Dental Cleaning - Child | $95 | 0% | $95 |
| Dental Exam - Comprehensive | $158 | 0% | $158 |
| Dental Exam - Periodic, Established Patient | $68 | 0% | $68 |
| Dental Filling - White (Resin): One Surface, Anterior | $242 | 0% | $242 |
| Dental Filling - White (Resin): One Surface, Posterior | $252 | 0% | $252 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $386 | 0% | $386 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $291 | 0% | $291 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $331 | 0% | $331 |
| Fluoride - Topical Application | $55 | 0% | $55 |
| Maintenance Therapy - Periodontal | $210 | 0% | $210 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $34 | 0% | $34 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $347 | 0% | $347 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $131 | 0% | $131 |
| Root Canal - Bicuspid Tooth | $1,155 | 0% | $1,155 |
| Root Canal - Molar | $2,919 | 0% | $2,919 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $70 | 0% | $70 |
| Tooth Extraction - Elevation and/or Forceps Removal | $252 | 0% | $252 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
| X-Ray - Complete Intraoral Series | $296 | 0% | $296 |
| X-Ray - Four Images, Bitewings | $86 | 0% | $86 |
| X-Ray - Intraoral, Periapical Radiographic Image | $41 | 0% | $41 |
| X-Ray - Two Images, Bitewings | $62 | 0% | $62 |
| X-Ray - Whole Mouth from Outside Mouth | $236 | 0% | $236 |
