| Dental Cleaning - Adult | $124 | 0% | $124 |
| Dental Cleaning - Child | $102 | 0% | $102 |
| Dental Exam - Comprehensive | $114 | 0% | $114 |
| Dental Exam - Periodic, Established Patient | $59 | 0% | $59 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | 0% | $208 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $378 | 0% | $378 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | 0% | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $185 | 0% | $185 |
| Dental Filling - White (Resin): One Surface, Posterior | $229 | 0% | $229 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $391 | 0% | $391 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | 0% | $271 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $288 | 0% | $288 |
| Flouride - Topical Varnish Application | $59 | 0% | $59 |
| Fluoride - Topical Application | $70 | 0% | $70 |
| Maintenance Therapy - Periodontal | $212 | 0% | $212 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $293 | 0% | $293 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $113 | 0% | $113 |
| Root Canal - Anterior Tooth | $1,254 | 0% | $1,254 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $66 | 0% | $66 |
| Tooth Extraction - Elevation and/or Forceps Removal | $269 | 0% | $269 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Complete Intraoral Series | $218 | 0% | $218 |
| X-Ray - Four Images, Bitewings | $81 | 0% | $81 |
| X-Ray - Intraoral, Periapical Radiographic Image | $47 | 0% | $47 |
| X-Ray - Two Images, Bitewings | $61 | 0% | $61 |
| X-Ray - Whole Mouth from Outside Mouth | $154 | 0% | $154 |
