| Dental Cleaning - Adult | $134 | 0% | $134 |
| Dental Cleaning - Child | $98 | 0% | $98 |
| Dental Exam - Comprehensive | $113 | 0% | $113 |
| Dental Exam - Periodic, Established Patient | $72 | 0% | $72 |
| Dental Filling - White (Resin): One Surface, Anterior | $238 | 0% | $238 |
| Dental Filling - White (Resin): One Surface, Posterior | $249 | 0% | $249 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $385 | 0% | $385 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $259 | 0% | $259 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $314 | 0% | $314 |
| Fluoride - Topical Application | $56 | 0% | $56 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $106 | 0% | $106 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $79 | 0% | $79 |
| Tooth Extraction - Elevation and/or Forceps Removal | $238 | 0% | $238 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | 0% | $38 |
| X-Ray - Complete Intraoral Series | $189 | 0% | $189 |
| X-Ray - Four Images, Bitewings | $92 | 0% | $92 |
| X-Ray - Intraoral, Periapical Radiographic Image | $44 | 0% | $44 |
| X-Ray - Two Images, Bitewings | $65 | 0% | $65 |
| X-Ray - Whole Mouth from Outside Mouth | $168 | 0% | $168 |
