| Dental Cleaning - Adult | $127 | 0% | $127 |
| Dental Cleaning - Child | $90 | 0% | $90 |
| Dental Exam - Comprehensive | $91 | 0% | $91 |
| Dental Exam - Periodic, Established Patient | $53 | 0% | $53 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $213 | 0% | $213 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $351 | 0% | $351 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $189 | 0% | $189 |
| Dental Filling - White (Resin): One Surface, Anterior | $192 | 0% | $192 |
| Dental Filling - White (Resin): One Surface, Posterior | $213 | 0% | $213 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $355 | 0% | $355 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $255 | 0% | $255 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $305 | 0% | $305 |
| Flouride - Topical Varnish Application | $49 | 0% | $49 |
| Fluoride - Topical Application | $49 | 0% | $49 |
| Maintenance Therapy - Periodontal | $190 | 0% | $190 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $322 | 0% | $322 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $112 | 0% | $112 |
| Root Canal - Anterior Tooth | $1,339 | 0% | $1,339 |
| Root Canal - Bicuspid Tooth | $1,614 | 0% | $1,614 |
| Root Canal - Molar | $1,572 | 0% | $1,572 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $64 | 0% | $64 |
| Tooth Extraction - Elevation and/or Forceps Removal | $202 | 0% | $202 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $36 | 0% | $36 |
| X-Ray - Complete Intraoral Series | $217 | 0% | $217 |
| X-Ray - Four Images, Bitewings | $86 | 0% | $86 |
| X-Ray - Intraoral, Periapical Radiographic Image | $45 | 0% | $45 |
| X-Ray - Two Images, Bitewings | $58 | 0% | $58 |
| X-Ray - Whole Mouth from Outside Mouth | $161 | 0% | $161 |
