| Dental Cleaning - Adult | $98 | 0% | $98 |
| Dental Cleaning - Child | $86 | 0% | $86 |
| Dental Exam - Comprehensive | $96 | 0% | $96 |
| Dental Exam - Periodic, Established Patient | $47 | 0% | $47 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $179 | 0% | $179 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $231 | 0% | $231 |
| Dental Filling - White (Resin): One Surface, Anterior | $158 | 0% | $158 |
| Dental Filling - White (Resin): One Surface, Posterior | $211 | 0% | $211 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $268 | 0% | $268 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $189 | 0% | $189 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $231 | 0% | $231 |
| Flouride - Topical Varnish Application | $45 | 0% | $45 |
| Fluoride - Topical Application | $37 | 0% | $37 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $80 | 0% | $80 |
| Root Canal - Molar | $1,103 | 0% | $1,103 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $57 | 0% | $57 |
| Tooth Extraction - Elevation and/or Forceps Removal | $189 | 0% | $189 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $21 | 0% | $21 |
| X-Ray - Complete Intraoral Series | $161 | 0% | $161 |
| X-Ray - Four Images, Bitewings | $65 | 0% | $65 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $47 | 0% | $47 |
| X-Ray - Whole Mouth from Outside Mouth | $126 | 0% | $126 |
