| Dental Cleaning - Adult | $107 | 0% | $107 |
| Dental Cleaning - Child | $82 | 0% | $82 |
| Dental Exam - Comprehensive | $96 | 0% | $96 |
| Dental Exam - Periodic, Established Patient | $45 | 0% | $45 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $174 | 0% | $174 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $290 | 0% | $290 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $260 | 0% | $260 |
| Dental Filling - White (Resin): One Surface, Anterior | $180 | 0% | $180 |
| Dental Filling - White (Resin): One Surface, Posterior | $197 | 0% | $197 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $284 | 0% | $284 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $189 | 0% | $189 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $236 | 0% | $236 |
| Flouride - Topical Varnish Application | $45 | 0% | $45 |
| Maintenance Therapy - Periodontal | $197 | 0% | $197 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $103 | 0% | $103 |
| Root Canal - Anterior Tooth | $758 | 0% | $758 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $69 | 0% | $69 |
| Tooth Extraction - Elevation and/or Forceps Removal | $189 | 0% | $189 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $21 | 0% | $21 |
| X-Ray - Complete Intraoral Series | $200 | 0% | $200 |
| X-Ray - Four Images, Bitewings | $74 | 0% | $74 |
| X-Ray - Intraoral, Periapical Radiographic Image | $29 | 0% | $29 |
| X-Ray - Two Images, Bitewings | $74 | 0% | $74 |
| X-Ray - Whole Mouth from Outside Mouth | $140 | 0% | $140 |
