| Dental Cleaning - Adult | $124 | 0% | $124 |
| Dental Cleaning - Child | $101 | 0% | $101 |
| Dental Exam - Comprehensive | $117 | 0% | $117 |
| Dental Exam - Periodic, Established Patient | $65 | 0% | $65 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $345 | 0% | $345 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $267 | 0% | $267 |
| Dental Filling - White (Resin): One Surface, Anterior | $219 | 0% | $219 |
| Dental Filling - White (Resin): One Surface, Posterior | $243 | 0% | $243 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $345 | 0% | $345 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $272 | 0% | $272 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $288 | 0% | $288 |
| Flouride - Topical Varnish Application | $57 | 0% | $57 |
| Maintenance Therapy - Periodontal | $319 | 0% | $319 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $93 | 0% | $93 |
| Root Canal - Molar | $1,329 | 0% | $1,329 |
| Tooth Extraction - Elevation and/or Forceps Removal | $240 | 0% | $240 |
| X-Ray - Four Images, Bitewings | $85 | 0% | $85 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $62 | 0% | $62 |
| X-Ray - Whole Mouth from Outside Mouth | $170 | 0% | $170 |
