| Dental Cleaning - Adult | $103 | 0% | $103 |
| Dental Cleaning - Child | $103 | 0% | $103 |
| Dental Exam - Comprehensive | $89 | 0% | $89 |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $125 | 0% | $125 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $191 | 0% | $191 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $156 | 0% | $156 |
| Dental Filling - White (Resin): One Surface, Anterior | $140 | 0% | $140 |
| Dental Filling - White (Resin): One Surface, Posterior | $186 | 0% | $186 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $337 | 0% | $337 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $198 | 0% | $198 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $238 | 0% | $238 |
| Fluoride - Topical Application | $43 | 0% | $43 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
| Root Canal - Anterior Tooth | $843 | 0% | $843 |
| Root Canal - Bicuspid Tooth | $1,008 | 0% | $1,008 |
| Root Canal - Molar | $1,196 | 0% | $1,196 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $57 | 0% | $57 |
| Tooth Extraction - Elevation and/or Forceps Removal | $180 | 0% | $180 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
| X-Ray - Four Images, Bitewings | $70 | 0% | $70 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $50 | 0% | $50 |
| X-Ray - Whole Mouth from Outside Mouth | $127 | 0% | $127 |
