| Dental Cleaning - Adult | $104 | 0% | $104 |
| Dental Cleaning - Child | $76 | 0% | $76 |
| Dental Exam - Comprehensive | $91 | 0% | $91 |
| Dental Exam - Periodic, Established Patient | $50 | 0% | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $177 | 0% | $177 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $313 | 0% | $313 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $251 | 0% | $251 |
| Dental Filling - White (Resin): One Surface, Anterior | $159 | 0% | $159 |
| Dental Filling - White (Resin): One Surface, Posterior | $177 | 0% | $177 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $332 | 0% | $332 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $205 | 0% | $205 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $251 | 0% | $251 |
| Flouride - Topical Varnish Application | $43 | 0% | $43 |
| Fluoride - Topical Application | $41 | 0% | $41 |
| Maintenance Therapy - Periodontal | $139 | 0% | $139 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $254 | 0% | $254 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
| Root Canal - Anterior Tooth | $801 | 0% | $801 |
| Root Canal - Bicuspid Tooth | $1,394 | 0% | $1,394 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $56 | 0% | $56 |
| Tooth Extraction - Elevation and/or Forceps Removal | $177 | 0% | $177 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $25 | 0% | $25 |
| X-Ray - Complete Intraoral Series | $145 | 0% | $145 |
| X-Ray - Four Images, Bitewings | $71 | 0% | $71 |
| X-Ray - Intraoral, Periapical Radiographic Image | $35 | 0% | $35 |
| X-Ray - Two Images, Bitewings | $51 | 0% | $51 |
| X-Ray - Whole Mouth from Outside Mouth | $131 | 0% | $131 |
