| Dental Cleaning - Adult | $124 | 0% | $124 |
| Dental Exam - Comprehensive | $154 | 0% | $154 |
| Dental Exam - Periodic, Established Patient | $59 | 0% | $59 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $223 | 0% | $223 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $287 | 0% | $287 |
| Dental Filling - White (Resin): One Surface, Anterior | $194 | 0% | $194 |
| Dental Filling - White (Resin): One Surface, Posterior | $223 | 0% | $223 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $238 | 0% | $238 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $311 | 0% | $311 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $131 | 0% | $131 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $33 | 0% | $33 |
| X-Ray - Complete Intraoral Series | $172 | 0% | $172 |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $40 | 0% | $40 |
| X-Ray - Two Images, Bitewings | $61 | 0% | $61 |
| X-Ray - Whole Mouth from Outside Mouth | $152 | 0% | $152 |
