| Dental Cleaning - Adult | $107 | 0% | $107 |
| Dental Cleaning - Child | $105 | 0% | $105 |
| Dental Exam - Comprehensive | $95 | 0% | $95 |
| Dental Exam - Periodic, Established Patient | $50 | 0% | $50 |
| 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 | $263 | 0% | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $298 | 0% | $298 |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | 0% | $189 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | 0% | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $205 | 0% | $205 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
| Flouride - Topical Varnish Application | $47 | 0% | $47 |
| Fluoride - Topical Application | $47 | 0% | $47 |
| Maintenance Therapy - Periodontal | $153 | 0% | $153 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $89 | 0% | $89 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $280 | 0% | $280 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
| Root Canal - Anterior Tooth | $877 | 0% | $877 |
| Root Canal - Bicuspid Tooth | $979 | 0% | $979 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | 0% | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $231 | 0% | $231 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $28 | 0% | $28 |
| X-Ray - Complete Intraoral Series | $148 | 0% | $148 |
| X-Ray - Four Images, Bitewings | $72 | 0% | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $69 | 0% | $69 |
| X-Ray - Whole Mouth from Outside Mouth | $131 | 0% | $131 |
