| Dental Cleaning - Adult | $144 | 0% | $144 |
| Dental Cleaning - Child | $88 | 0% | $88 |
| Dental Exam - Comprehensive | $132 | 0% | $132 |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $384 | 0% | $384 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $552 | 0% | $552 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $230 | 0% | $230 |
| Dental Filling - White (Resin): One Surface, Anterior | $195 | 0% | $195 |
| Dental Filling - White (Resin): One Surface, Posterior | $195 | 0% | $195 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $376 | 0% | $376 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $277 | 0% | $277 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $312 | 0% | $312 |
| Flouride - Topical Varnish Application | $48 | 0% | $48 |
| Maintenance Therapy - Periodontal | $228 | 0% | $228 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $267 | 0% | $267 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $140 | 0% | $140 |
| Root Canal - Molar | $1,491 | 0% | $1,491 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $78 | 0% | $78 |
| Tooth Extraction - Elevation and/or Forceps Removal | $249 | 0% | $249 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | 0% | $30 |
| X-Ray - Complete Intraoral Series | $196 | 0% | $196 |
| X-Ray - Four Images, Bitewings | $95 | 0% | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
| X-Ray - Two Images, Bitewings | $80 | 0% | $80 |
