| Dental Cleaning - Adult | $116 | 0% | $116 |
| Dental Exam - Comprehensive | $105 | 0% | $105 |
| Dental Exam - Periodic, Established Patient | $57 | 0% | $57 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $389 | 0% | $389 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $310 | 0% | $310 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | 0% | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $168 | 0% | $168 |
| Dental Filling - White (Resin): One Surface, Posterior | $291 | 0% | $291 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $620 | 0% | $620 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $210 | 0% | $210 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $546 | 0% | $546 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $105 | 0% | $105 |
| Root Canal - Anterior Tooth | $893 | 0% | $893 |
| X-Ray - Complete Intraoral Series | $152 | 0% | $152 |
| X-Ray - Four Images, Bitewings | $89 | 0% | $89 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
