| Dental Cleaning - Adult | $121 | 0% | $121 |
| Dental Cleaning - Child | $90 | 0% | $90 |
| Dental Exam - Comprehensive | $110 | 0% | $110 |
| Dental Exam - Periodic, Established Patient | $70 | 0% | $70 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $226 | 0% | $226 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $289 | 0% | $289 |
| Dental Filling - White (Resin): One Surface, Anterior | $202 | 0% | $202 |
| Dental Filling - White (Resin): One Surface, Posterior | $226 | 0% | $226 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $348 | 0% | $348 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $274 | 0% | $274 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $289 | 0% | $289 |
| Flouride - Topical Varnish Application | $51 | 0% | $51 |
| Maintenance Therapy - Periodontal | $175 | 0% | $175 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $314 | 0% | $314 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $98 | 0% | $98 |
| Root Canal - Anterior Tooth | $1,024 | 0% | $1,024 |
| Tooth Extraction - Elevation and/or Forceps Removal | $229 | 0% | $229 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
| X-Ray - Complete Intraoral Series | $168 | 0% | $168 |
| X-Ray - Four Images, Bitewings | $82 | 0% | $82 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
| X-Ray - Two Images, Bitewings | $57 | 0% | $57 |
