| Dental Cleaning - Adult | $110 | 0% | $110 |
| Dental Cleaning - Child | $89 | 0% | $89 |
| Dental Exam - Comprehensive | $91 | 0% | $91 |
| Dental Exam - Periodic, Established Patient | $51 | 0% | $51 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $168 | 0% | $168 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $263 | 0% | $263 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $210 | 0% | $210 |
| Dental Filling - White (Resin): One Surface, Anterior | $167 | 0% | $167 |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | 0% | $189 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | 0% | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $205 | 0% | $205 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
| Flouride - Topical Varnish Application | $41 | 0% | $41 |
| Fluoride - Topical Application | $41 | 0% | $41 |
| Maintenance Therapy - Periodontal | $150 | 0% | $150 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $280 | 0% | $280 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
| Root Canal - Anterior Tooth | $877 | 0% | $877 |
| Root Canal - Bicuspid Tooth | $979 | 0% | $979 |
| Root Canal - Molar | $1,219 | 0% | $1,219 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | 0% | $60 |
| Tooth Extraction - Elevation and/or Forceps Removal | $215 | 0% | $215 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $55 | 0% | $55 |
| X-Ray - Complete Intraoral Series | $153 | 0% | $153 |
| X-Ray - Four Images, Bitewings | $72 | 0% | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $51 | 0% | $51 |
| X-Ray - Whole Mouth from Outside Mouth | $145 | 0% | $145 |
