| Dental Cleaning - Adult | $114 | 0% | $114 |
| Dental Cleaning - Child | $102 | 0% | $102 |
| Dental Exam - Comprehensive | $131 | 0% | $131 |
| Dental Exam - Periodic, Established Patient | $67 | 0% | $67 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | 0% | $189 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | 0% | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $289 | 0% | $289 |
| Dental Filling - White (Resin): One Surface, Anterior | $194 | 0% | $194 |
| Dental Filling - White (Resin): One Surface, Posterior | $209 | 0% | $209 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $352 | 0% | $352 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $236 | 0% | $236 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $289 | 0% | $289 |
| Fluoride - Topical Application | $43 | 0% | $43 |
| Maintenance Therapy - Periodontal | $152 | 0% | $152 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $72 | 0% | $72 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $356 | 0% | $356 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $121 | 0% | $121 |
| Root Canal - Anterior Tooth | $1,049 | 0% | $1,049 |
| Root Canal - Bicuspid Tooth | $1,024 | 0% | $1,024 |
| Root Canal - Molar | $1,208 | 0% | $1,208 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $78 | 0% | $78 |
| Tooth Extraction - Elevation and/or Forceps Removal | $288 | 0% | $288 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | 0% | $30 |
| X-Ray - Complete Intraoral Series | $225 | 0% | $225 |
| X-Ray - Four Images, Bitewings | $93 | 0% | $93 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
| X-Ray - Whole Mouth from Outside Mouth | $149 | 0% | $149 |
