| Dental Cleaning - Adult | $206 | 0% | $206 |
| Dental Cleaning - Child | $166 | 0% | $166 |
| Dental Exam - Comprehensive | $189 | 0% | $189 |
| Dental Exam - Periodic, Established Patient | $105 | 0% | $105 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $372 | 0% | $372 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $674 | 0% | $674 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $519 | 0% | $519 |
| Dental Filling - White (Resin): One Surface, Posterior | $372 | 0% | $372 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $674 | 0% | $674 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $414 | 0% | $414 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $519 | 0% | $519 |
| Flouride - Topical Varnish Application | $101 | 0% | $101 |
| Maintenance Therapy - Periodontal | $336 | 0% | $336 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $544 | 0% | $544 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $174 | 0% | $174 |
| Root Canal - Molar | $2,392 | 0% | $2,392 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $116 | 0% | $116 |
| Tooth Extraction - Elevation and/or Forceps Removal | $389 | 0% | $389 |
| X-Ray - Complete Intraoral Series | $288 | 0% | $288 |
| X-Ray - Four Images, Bitewings | $139 | 0% | $139 |
| X-Ray - Intraoral, Periapical Radiographic Image | $67 | 0% | $67 |
| X-Ray - Two Images, Bitewings | $99 | 0% | $99 |
| X-Ray - Whole Mouth from Outside Mouth | $275 | 0% | $275 |
