| Dental Cleaning - Adult | $103 | 0% | $103 |
| Dental Cleaning - Child | $83 | 0% | $83 |
| Dental Exam - Comprehensive | $101 | 0% | $101 |
| Dental Exam - Periodic, Established Patient | $51 | 0% | $51 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $195 | 0% | $195 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $336 | 0% | $336 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $260 | 0% | $260 |
| Dental Filling - White (Resin): One Surface, Anterior | $177 | 0% | $177 |
| Dental Filling - White (Resin): One Surface, Posterior | $195 | 0% | $195 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $347 | 0% | $347 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $221 | 0% | $221 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $260 | 0% | $260 |
| Flouride - Topical Varnish Application | $53 | 0% | $53 |
| Fluoride - Topical Application | $43 | 0% | $43 |
| Maintenance Therapy - Periodontal | $160 | 0% | $160 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $273 | 0% | $273 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $87 | 0% | $87 |
| Root Canal - Bicuspid Tooth | $966 | 0% | $966 |
| Root Canal - Molar | $1,260 | 0% | $1,260 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $57 | 0% | $57 |
| Tooth Extraction - Elevation and/or Forceps Removal | $188 | 0% | $188 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Complete Intraoral Series | $151 | 0% | $151 |
| X-Ray - Four Images, Bitewings | $70 | 0% | $70 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $53 | 0% | $53 |
