| Dental Cleaning - Adult | $107 | 0% | $107 |
| Dental Cleaning - Child | $80 | 0% | $80 |
| Dental Exam - Comprehensive | $88 | 0% | $88 |
| Dental Exam - Periodic, Established Patient | $50 | 0% | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $195 | 0% | $195 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $428 | 0% | $428 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $261 | 0% | $261 |
| Dental Filling - White (Resin): One Surface, Anterior | $207 | 0% | $207 |
| Dental Filling - White (Resin): One Surface, Posterior | $195 | 0% | $195 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | 0% | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $289 | 0% | $289 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
| Flouride - Topical Varnish Application | $43 | 0% | $43 |
| Fluoride - Topical Application | $68 | 0% | $68 |
| Maintenance Therapy - Periodontal | $193 | 0% | $193 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $310 | 0% | $310 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $87 | 0% | $87 |
| Root Canal - Anterior Tooth | $1,070 | 0% | $1,070 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $59 | 0% | $59 |
| Tooth Extraction - Elevation and/or Forceps Removal | $236 | 0% | $236 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $45 | 0% | $45 |
| X-Ray - Complete Intraoral Series | $148 | 0% | $148 |
| X-Ray - Four Images, Bitewings | $72 | 0% | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $50 | 0% | $50 |
| X-Ray - Two Images, Bitewings | $51 | 0% | $51 |
| X-Ray - Whole Mouth from Outside Mouth | $204 | 0% | $204 |
