| Dental Cleaning - Adult | $95 | 0% | $95 |
| Dental Cleaning - Child | $68 | 0% | $68 |
| Dental Exam - Comprehensive | $96 | 0% | $96 |
| Dental Exam - Periodic, Established Patient | $49 | 0% | $49 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $186 | 0% | $186 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $216 | 0% | $216 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $212 | 0% | $212 |
| Dental Filling - White (Resin): One Surface, Anterior | $145 | 0% | $145 |
| Dental Filling - White (Resin): One Surface, Posterior | $154 | 0% | $154 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $308 | 0% | $308 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $191 | 0% | $191 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $303 | 0% | $303 |
| Fluoride - Topical Application | $39 | 0% | $39 |
| Maintenance Therapy - Periodontal | $197 | 0% | $197 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $315 | 0% | $315 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $71 | 0% | $71 |
| Root Canal - Molar | $1,050 | 0% | $1,050 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $18 | 0% | $18 |
| X-Ray - Complete Intraoral Series | $137 | 0% | $137 |
| X-Ray - Four Images, Bitewings | $61 | 0% | $61 |
| X-Ray - Intraoral, Periapical Radiographic Image | $28 | 0% | $28 |
| X-Ray - Two Images, Bitewings | $40 | 0% | $40 |
