| Dental Cleaning - Adult | $112 | 0% | $112 |
| Dental Cleaning - Child | $112 | 0% | $112 |
| Dental Exam - Comprehensive | $108 | 0% | $108 |
| Dental Exam - Periodic, Established Patient | $57 | 0% | $57 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $205 | 0% | $205 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $349 | 0% | $349 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $279 | 0% | $279 |
| Dental Filling - White (Resin): One Surface, Anterior | $219 | 0% | $219 |
| Dental Filling - White (Resin): One Surface, Posterior | $215 | 0% | $215 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $365 | 0% | $365 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $253 | 0% | $253 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $293 | 0% | $293 |
| Flouride - Topical Varnish Application | $48 | 0% | $48 |
| Maintenance Therapy - Periodontal | $179 | 0% | $179 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $313 | 0% | $313 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $98 | 0% | $98 |
| Root Canal - Anterior Tooth | $2,048 | 0% | $2,048 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $66 | 0% | $66 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
| X-Ray - Complete Intraoral Series | $177 | 0% | $177 |
| X-Ray - Four Images, Bitewings | $82 | 0% | $82 |
| X-Ray - Intraoral, Periapical Radiographic Image | $37 | 0% | $37 |
| X-Ray - Two Images, Bitewings | $54 | 0% | $54 |
| X-Ray - Whole Mouth from Outside Mouth | $146 | 0% | $146 |
