| Dental Cleaning - Adult | $119 | 0% | $119 |
| Dental Cleaning - Child | $92 | 0% | $92 |
| Dental Exam - Comprehensive | $106 | 0% | $106 |
| Dental Exam - Periodic, Established Patient | $68 | 0% | $68 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $221 | 0% | $221 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $315 | 0% | $315 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $277 | 0% | $277 |
| Dental Filling - White (Resin): One Surface, Anterior | $200 | 0% | $200 |
| Dental Filling - White (Resin): One Surface, Posterior | $217 | 0% | $217 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $383 | 0% | $383 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $244 | 0% | $244 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $277 | 0% | $277 |
| Fluoride - Topical Application | $71 | 0% | $71 |
| Maintenance Therapy - Periodontal | $175 | 0% | $175 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $306 | 0% | $306 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $95 | 0% | $95 |
| Root Canal - Bicuspid Tooth | $1,495 | 0% | $1,495 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $82 | 0% | $82 |
| Tooth Extraction - Elevation and/or Forceps Removal | $196 | 0% | $196 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $32 | 0% | $32 |
| X-Ray - Complete Intraoral Series | $165 | 0% | $165 |
| X-Ray - Four Images, Bitewings | $79 | 0% | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | 0% | $36 |
| X-Ray - Two Images, Bitewings | $78 | 0% | $78 |
| X-Ray - Whole Mouth from Outside Mouth | $168 | 0% | $168 |
