| Dental Cleaning - Adult | $131 | 0% | $131 |
| Dental Cleaning - Child | $100 | 0% | $100 |
| Dental Exam - Comprehensive | $79 | 0% | $79 |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $173 | 0% | $173 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $410 | 0% | $410 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $278 | 0% | $278 |
| Dental Filling - White (Resin): One Surface, Anterior | $205 | 0% | $205 |
| Dental Filling - White (Resin): One Surface, Posterior | $194 | 0% | $194 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $410 | 0% | $410 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $310 | 0% | $310 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $299 | 0% | $299 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $100 | 0% | $100 |
| Root Canal - Anterior Tooth | $1,150 | 0% | $1,150 |
| Root Canal - Bicuspid Tooth | $1,391 | 0% | $1,391 |
| Root Canal - Molar | $1,496 | 0% | $1,496 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $100 | 0% | $100 |
| Tooth Extraction - Elevation and/or Forceps Removal | $247 | 0% | $247 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Complete Intraoral Series | $210 | 0% | $210 |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
| X-Ray - Two Images, Bitewings | $53 | 0% | $53 |
| X-Ray - Whole Mouth from Outside Mouth | $173 | 0% | $173 |
