| Dental Cleaning - Adult | $139 | 0% | $139 |
| Dental Cleaning - Child | $83 | 0% | $83 |
| Dental Exam - Comprehensive | $103 | 0% | $103 |
| Dental Exam - Periodic, Established Patient | $62 | 0% | $62 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $407 | 0% | $407 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $307 | 0% | $307 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $251 | 0% | $251 |
| Dental Filling - White (Resin): One Surface, Anterior | $250 | 0% | $250 |
| Dental Filling - White (Resin): One Surface, Posterior | $320 | 0% | $320 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $290 | 0% | $290 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $320 | 0% | $320 |
| Flouride - Topical Varnish Application | $50 | 0% | $50 |
| Maintenance Therapy - Periodontal | $198 | 0% | $198 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $362 | 0% | $362 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | 0% | $100 |
| Root Canal - Anterior Tooth | $1,974 | 0% | $1,974 |
| Root Canal - Bicuspid Tooth | $1,150 | 0% | $1,150 |
| Root Canal - Molar | $1,470 | 0% | $1,470 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | 0% | $69 |
| Tooth Extraction - Elevation and/or Forceps Removal | $231 | 0% | $231 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $27 | 0% | $27 |
| X-Ray - Complete Intraoral Series | $197 | 0% | $197 |
| X-Ray - Four Images, Bitewings | $100 | 0% | $100 |
| X-Ray - Intraoral, Periapical Radiographic Image | $48 | 0% | $48 |
| X-Ray - Two Images, Bitewings | $71 | 0% | $71 |
| X-Ray - Whole Mouth from Outside Mouth | $189 | 0% | $189 |
