| Dental Cleaning - Adult | $221 | 0% | $221 |
| Dental Cleaning - Child | $185 | 0% | $185 |
| Dental Exam - Comprehensive | $144 | 0% | $144 |
| Dental Exam - Periodic, Established Patient | $95 | 0% | $95 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $194 | 0% | $194 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $578 | 0% | $578 |
| Dental Filling - White (Resin): One Surface, Posterior | $420 | 0% | $420 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $683 | 0% | $683 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $525 | 0% | $525 |
| Fluoride - Topical Application | $84 | 0% | $84 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $189 | 0% | $189 |
| Tooth Extraction - Elevation and/or Forceps Removal | $315 | 0% | $315 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $57 | 0% | $57 |
| X-Ray - Intraoral, Periapical Radiographic Image | $63 | 0% | $63 |
| X-Ray - Two Images, Bitewings | $105 | 0% | $105 |
| X-Ray - Whole Mouth from Outside Mouth | $252 | 0% | $252 |
