| Dental Cleaning - Adult | $123 | 0% | $123 |
| Dental Cleaning - Child | $88 | 0% | $88 |
| Dental Exam - Comprehensive | $106 | 0% | $106 |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $219 | 0% | $219 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $345 | 0% | $345 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $287 | 0% | $287 |
| Dental Filling - White (Resin): One Surface, Anterior | $187 | 0% | $187 |
| Dental Filling - White (Resin): One Surface, Posterior | $219 | 0% | $219 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $356 | 0% | $356 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $248 | 0% | $248 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $287 | 0% | $287 |
| Flouride - Topical Varnish Application | $42 | 0% | $42 |
| Fluoride - Topical Application | $45 | 0% | $45 |
| Maintenance Therapy - Periodontal | $185 | 0% | $185 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $313 | 0% | $313 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $109 | 0% | $109 |
| Root Canal - Anterior Tooth | $1,066 | 0% | $1,066 |
| Root Canal - Bicuspid Tooth | $1,267 | 0% | $1,267 |
| Root Canal - Molar | $1,572 | 0% | $1,572 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | 0% | $69 |
| Tooth Extraction - Elevation and/or Forceps Removal | $233 | 0% | $233 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
| X-Ray - Complete Intraoral Series | $202 | 0% | $202 |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $44 | 0% | $44 |
| X-Ray - Two Images, Bitewings | $61 | 0% | $61 |
| X-Ray - Whole Mouth from Outside Mouth | $156 | 0% | $156 |
