| Dental Cleaning - Adult | $108 | 0% | $108 |
| Dental Cleaning - Child | $88 | 0% | $88 |
| Dental Exam - Comprehensive | $100 | 0% | $100 |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | 0% | $189 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $228 | 0% | $228 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $189 | 0% | $189 |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | 0% | $184 |
| Dental Filling - White (Resin): One Surface, Posterior | $200 | 0% | $200 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $347 | 0% | $347 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $205 | 0% | $205 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
| Fluoride - Topical Application | $45 | 0% | $45 |
| Maintenance Therapy - Periodontal | $153 | 0% | $153 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $90 | 0% | $90 |
| Root Canal - Anterior Tooth | $893 | 0% | $893 |
| Root Canal - Molar | $1,323 | 0% | $1,323 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $60 | 0% | $60 |
| Tooth Extraction - Elevation and/or Forceps Removal | $205 | 0% | $205 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $37 | 0% | $37 |
| X-Ray - Complete Intraoral Series | $158 | 0% | $158 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
| X-Ray - Two Images, Bitewings | $58 | 0% | $58 |
