| Dental Cleaning - Adult | $128 | 0% | $128 |
| Dental Cleaning - Child | $118 | 0% | $118 |
| Dental Exam - Comprehensive | $108 | 0% | $108 |
| Dental Exam - Periodic, Established Patient | $64 | 0% | $64 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | 0% | $208 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | 0% | $326 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | 0% | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $210 | 0% | $210 |
| Dental Filling - White (Resin): One Surface, Posterior | $225 | 0% | $225 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $370 | 0% | $370 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $271 | 0% | $271 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $306 | 0% | $306 |
| Flouride - Topical Varnish Application | $66 | 0% | $66 |
| Fluoride - Topical Application | $66 | 0% | $66 |
| Maintenance Therapy - Periodontal | $212 | 0% | $212 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $395 | 0% | $395 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $113 | 0% | $113 |
| Root Canal - Anterior Tooth | $1,158 | 0% | $1,158 |
| Root Canal - Bicuspid Tooth | $1,541 | 0% | $1,541 |
| Root Canal - Molar | $1,630 | 0% | $1,630 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $79 | 0% | $79 |
| Tooth Extraction - Elevation and/or Forceps Removal | $260 | 0% | $260 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | 0% | $30 |
| X-Ray - Complete Intraoral Series | $197 | 0% | $197 |
| X-Ray - Four Images, Bitewings | $95 | 0% | $95 |
| X-Ray - Intraoral, Periapical Radiographic Image | $50 | 0% | $50 |
| X-Ray - Two Images, Bitewings | $70 | 0% | $70 |
| X-Ray - Whole Mouth from Outside Mouth | $171 | 0% | $171 |
