| Dental Cleaning - Adult | $121 | 0% | $121 |
| Dental Exam - Comprehensive | $90 | 0% | $90 |
| Dental Exam - Periodic, Established Patient | $61 | 0% | $61 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $216 | 0% | $216 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $362 | 0% | $362 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $299 | 0% | $299 |
| Dental Filling - White (Resin): One Surface, Posterior | $226 | 0% | $226 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $362 | 0% | $362 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $259 | 0% | $259 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $299 | 0% | $299 |
| Maintenance Therapy - Periodontal | $192 | 0% | $192 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $104 | 0% | $104 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $35 | 0% | $35 |
| X-Ray - Complete Intraoral Series | $170 | 0% | $170 |
| X-Ray - Four Images, Bitewings | $68 | 0% | $68 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
