| Dental Cleaning - Adult | $101 | 0% | $101 |
| Dental Cleaning - Child | $82 | 0% | $82 |
| Dental Exam - Comprehensive | $89 | 0% | $89 |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $169 | 0% | $169 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $226 | 0% | $226 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $189 | 0% | $189 |
| Dental Filling - White (Resin): One Surface, Anterior | $160 | 0% | $160 |
| Dental Filling - White (Resin): One Surface, Posterior | $186 | 0% | $186 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $337 | 0% | $337 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $198 | 0% | $198 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
| Flouride - Topical Varnish Application | $41 | 0% | $41 |
| Fluoride - Topical Application | $43 | 0% | $43 |
| Maintenance Therapy - Periodontal | $149 | 0% | $149 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $107 | 0% | $107 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $272 | 0% | $272 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $87 | 0% | $87 |
| Root Canal - Anterior Tooth | $843 | 0% | $843 |
| Root Canal - Bicuspid Tooth | $894 | 0% | $894 |
| Root Canal - Molar | $1,196 | 0% | $1,196 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | 0% | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $188 | 0% | $188 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $25 | 0% | $25 |
| X-Ray - Complete Intraoral Series | $145 | 0% | $145 |
| X-Ray - Four Images, Bitewings | $70 | 0% | $70 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
| X-Ray - Whole Mouth from Outside Mouth | $131 | 0% | $131 |
