| Dental Cleaning - Adult | $116 | 0% | $116 |
| Dental Cleaning - Child | $92 | 0% | $92 |
| Dental Exam - Comprehensive | $95 | 0% | $95 |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $217 | 0% | $217 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $343 | 0% | $343 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $269 | 0% | $269 |
| Dental Filling - White (Resin): One Surface, Anterior | $189 | 0% | $189 |
| Dental Filling - White (Resin): One Surface, Posterior | $209 | 0% | $209 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $337 | 0% | $337 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $233 | 0% | $233 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $274 | 0% | $274 |
| Flouride - Topical Varnish Application | $50 | 0% | $50 |
| Fluoride - Topical Application | $47 | 0% | $47 |
| Maintenance Therapy - Periodontal | $184 | 0% | $184 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $124 | 0% | $124 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $331 | 0% | $331 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $111 | 0% | $111 |
| Root Canal - Anterior Tooth | $1,213 | 0% | $1,213 |
| Root Canal - Bicuspid Tooth | $1,465 | 0% | $1,465 |
| Root Canal - Molar | $1,614 | 0% | $1,614 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $65 | 0% | $65 |
| Tooth Extraction - Elevation and/or Forceps Removal | $260 | 0% | $260 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
| X-Ray - Complete Intraoral Series | $171 | 0% | $171 |
| X-Ray - Four Images, Bitewings | $81 | 0% | $81 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
| X-Ray - Whole Mouth from Outside Mouth | $149 | 0% | $149 |
