| Dental Cleaning - Adult | $109 | 0% | $109 |
| Dental Cleaning - Child | $88 | 0% | $88 |
| Dental Exam - Comprehensive | $149 | 0% | $149 |
| Dental Exam - Periodic, Established Patient | $51 | 0% | $51 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $169 | 0% | $169 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $321 | 0% | $321 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $231 | 0% | $231 |
| Dental Filling - White (Resin): One Surface, Anterior | $164 | 0% | $164 |
| Dental Filling - White (Resin): One Surface, Posterior | $169 | 0% | $169 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $321 | 0% | $321 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $205 | 0% | $205 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $231 | 0% | $231 |
| Fluoride - Topical Application | $45 | 0% | $45 |
| Maintenance Therapy - Periodontal | $158 | 0% | $158 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $131 | 0% | $131 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $552 | 0% | $552 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $92 | 0% | $92 |
| Root Canal - Anterior Tooth | $2,203 | 0% | $2,203 |
| Root Canal - Bicuspid Tooth | $1,220 | 0% | $1,220 |
| Root Canal - Molar | $1,399 | 0% | $1,399 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $90 | 0% | $90 |
| Tooth Extraction - Elevation and/or Forceps Removal | $299 | 0% | $299 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $34 | 0% | $34 |
| X-Ray - Complete Intraoral Series | $167 | 0% | $167 |
| X-Ray - Four Images, Bitewings | $78 | 0% | $78 |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
| X-Ray - Two Images, Bitewings | $62 | 0% | $62 |
| X-Ray - Whole Mouth from Outside Mouth | $187 | 0% | $187 |
