| Dental Cleaning - Adult | $107 | 0% | $107 |
| Dental Cleaning - Child | $86 | 0% | $86 |
| Dental Exam - Comprehensive | $91 | 0% | $91 |
| Dental Exam - Periodic, Established Patient | $50 | 0% | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $149 | 0% | $149 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $228 | 0% | $228 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $187 | 0% | $187 |
| Dental Filling - White (Resin): One Surface, Anterior | $194 | 0% | $194 |
| Dental Filling - White (Resin): One Surface, Posterior | $321 | 0% | $321 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $563 | 0% | $563 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $244 | 0% | $244 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $439 | 0% | $439 |
| Flouride - Topical Varnish Application | $43 | 0% | $43 |
| Fluoride - Topical Application | $43 | 0% | $43 |
| Maintenance Therapy - Periodontal | $216 | 0% | $216 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $107 | 0% | $107 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $506 | 0% | $506 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $91 | 0% | $91 |
| Root Canal - Anterior Tooth | $877 | 0% | $877 |
| Root Canal - Bicuspid Tooth | $979 | 0% | $979 |
| Root Canal - Molar | $1,625 | 0% | $1,625 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | 0% | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $186 | 0% | $186 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
| X-Ray - Complete Intraoral Series | $252 | 0% | $252 |
| X-Ray - Four Images, Bitewings | $72 | 0% | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $51 | 0% | $51 |
| X-Ray - Whole Mouth from Outside Mouth | $131 | 0% | $131 |
