| Dental Cleaning - Adult | $126 | 0% | $126 |
| Dental Cleaning - Child | $103 | 0% | $103 |
| Dental Exam - Comprehensive | $144 | 0% | $144 |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $278 | 0% | $278 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $413 | 0% | $413 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $338 | 0% | $338 |
| Dental Filling - White (Resin): One Surface, Anterior | $253 | 0% | $253 |
| Dental Filling - White (Resin): One Surface, Posterior | $278 | 0% | $278 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $433 | 0% | $433 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $309 | 0% | $309 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $338 | 0% | $338 |
| Flouride - Topical Varnish Application | $56 | 0% | $56 |
| Fluoride - Topical Application | $56 | 0% | $56 |
| Maintenance Therapy - Periodontal | $176 | 0% | $176 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $169 | 0% | $169 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $357 | 0% | $357 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $122 | 0% | $122 |
| Root Canal - Anterior Tooth | $1,181 | 0% | $1,181 |
| Root Canal - Bicuspid Tooth | $979 | 0% | $979 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | 0% | $74 |
| Tooth Extraction - Elevation and/or Forceps Removal | $247 | 0% | $247 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | 0% | $36 |
| X-Ray - Complete Intraoral Series | $281 | 0% | $281 |
| X-Ray - Four Images, Bitewings | $98 | 0% | $98 |
| X-Ray - Intraoral, Periapical Radiographic Image | $46 | 0% | $46 |
| X-Ray - Two Images, Bitewings | $72 | 0% | $72 |
| X-Ray - Whole Mouth from Outside Mouth | $184 | 0% | $184 |
