| Dental Cleaning - Adult | $116 | 0% | $116 |
| Dental Cleaning - Child | $89 | 0% | $89 |
| Dental Exam - Comprehensive | $116 | 0% | $116 |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $319 | 0% | $319 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $347 | 0% | $347 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $289 | 0% | $289 |
| Dental Filling - White (Resin): One Surface, Anterior | $236 | 0% | $236 |
| Dental Filling - White (Resin): One Surface, Posterior | $236 | 0% | $236 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $347 | 0% | $347 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $263 | 0% | $263 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $289 | 0% | $289 |
| Flouride - Topical Varnish Application | $53 | 0% | $53 |
| Fluoride - Topical Application | $53 | 0% | $53 |
| Maintenance Therapy - Periodontal | $332 | 0% | $332 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $326 | 0% | $326 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | 0% | $95 |
| Root Canal - Anterior Tooth | $1,050 | 0% | $1,050 |
| Root Canal - Bicuspid Tooth | $2,259 | 0% | $2,259 |
| Root Canal - Molar | $1,365 | 0% | $1,365 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $58 | 0% | $58 |
| Tooth Extraction - Elevation and/or Forceps Removal | $236 | 0% | $236 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | 0% | $30 |
| X-Ray - Complete Intraoral Series | $152 | 0% | $152 |
| X-Ray - Four Images, Bitewings | $79 | 0% | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
