| Dental Cleaning - Adult | $114 | 0% | $114 |
| Dental Cleaning - Child | $85 | 0% | $85 |
| Dental Exam - Comprehensive | $108 | 0% | $108 |
| Dental Exam - Periodic, Established Patient | $63 | 0% | $63 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $238 | 0% | $238 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $410 | 0% | $410 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $323 | 0% | $323 |
| Dental Filling - White (Resin): One Surface, Anterior | $219 | 0% | $219 |
| Dental Filling - White (Resin): One Surface, Posterior | $238 | 0% | $238 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $410 | 0% | $410 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $290 | 0% | $290 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $323 | 0% | $323 |
| Flouride - Topical Varnish Application | $50 | 0% | $50 |
| Fluoride - Topical Application | $43 | 0% | $43 |
| Maintenance Therapy - Periodontal | $174 | 0% | $174 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $143 | 0% | $143 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $314 | 0% | $314 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $96 | 0% | $96 |
| Root Canal - Anterior Tooth | $1,425 | 0% | $1,425 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $74 | 0% | $74 |
| Tooth Extraction - Elevation and/or Forceps Removal | $236 | 0% | $236 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Complete Intraoral Series | $170 | 0% | $170 |
| X-Ray - Four Images, Bitewings | $75 | 0% | $75 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
| X-Ray - Two Images, Bitewings | $57 | 0% | $57 |
| X-Ray - Whole Mouth from Outside Mouth | $139 | 0% | $139 |
