| Dental Cleaning - Adult | $142 | 0% | $142 |
| Dental Cleaning - Child | $121 | 0% | $121 |
| Dental Exam - Comprehensive | $108 | 0% | $108 |
| Dental Exam - Periodic, Established Patient | $100 | 0% | $100 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $313 | 0% | $313 |
| Dental Filling - White (Resin): One Surface, Anterior | $244 | 0% | $244 |
| Dental Filling - White (Resin): One Surface, Posterior | $294 | 0% | $294 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $357 | 0% | $357 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $278 | 0% | $278 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $310 | 0% | $310 |
| Fluoride - Topical Application | $79 | 0% | $79 |
| Maintenance Therapy - Periodontal | $184 | 0% | $184 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $104 | 0% | $104 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $83 | 0% | $83 |
| Tooth Extraction - Elevation and/or Forceps Removal | $263 | 0% | $263 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $49 | 0% | $49 |
| X-Ray - Complete Intraoral Series | $226 | 0% | $226 |
| X-Ray - Four Images, Bitewings | $142 | 0% | $142 |
| X-Ray - Intraoral, Periapical Radiographic Image | $60 | 0% | $60 |
| X-Ray - Two Images, Bitewings | $104 | 0% | $104 |
| X-Ray - Whole Mouth from Outside Mouth | $299 | 0% | $299 |
