| Dental Cleaning - Adult | $119 | 0% | $119 |
| Dental Cleaning - Child | $111 | 0% | $111 |
| Dental Exam - Comprehensive | $114 | 0% | $114 |
| Dental Exam - Periodic, Established Patient | $60 | 0% | $60 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $184 | 0% | $184 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $359 | 0% | $359 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $246 | 0% | $246 |
| Dental Filling - White (Resin): One Surface, Anterior | $232 | 0% | $232 |
| Dental Filling - White (Resin): One Surface, Posterior | $244 | 0% | $244 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $359 | 0% | $359 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $237 | 0% | $237 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $265 | 0% | $265 |
| Flouride - Topical Varnish Application | $58 | 0% | $58 |
| Fluoride - Topical Application | $45 | 0% | $45 |
| Maintenance Therapy - Periodontal | $156 | 0% | $156 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $475 | 0% | $475 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $114 | 0% | $114 |
| Root Canal - Bicuspid Tooth | $1,386 | 0% | $1,386 |
| Root Canal - Molar | $1,616 | 0% | $1,616 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $79 | 0% | $79 |
| Tooth Extraction - Elevation and/or Forceps Removal | $270 | 0% | $270 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $42 | 0% | $42 |
| X-Ray - Complete Intraoral Series | $181 | 0% | $181 |
| X-Ray - Four Images, Bitewings | $96 | 0% | $96 |
| X-Ray - Intraoral, Periapical Radiographic Image | $47 | 0% | $47 |
| X-Ray - Two Images, Bitewings | $69 | 0% | $69 |
| X-Ray - Whole Mouth from Outside Mouth | $161 | 0% | $161 |
