| Dental Cleaning - Adult | $112 | 0% | $112 |
| Dental Cleaning - Child | $89 | 0% | $89 |
| Dental Exam - Comprehensive | $96 | 0% | $96 |
| Dental Exam - Periodic, Established Patient | $54 | 0% | $54 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $226 | 0% | $226 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $383 | 0% | $383 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $306 | 0% | $306 |
| Dental Filling - White (Resin): One Surface, Anterior | $212 | 0% | $212 |
| Dental Filling - White (Resin): One Surface, Posterior | $226 | 0% | $226 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $383 | 0% | $383 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $412 | 0% | $412 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $306 | 0% | $306 |
| Flouride - Topical Varnish Application | $43 | 0% | $43 |
| Maintenance Therapy - Periodontal | $159 | 0% | $159 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $69 | 0% | $69 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $322 | 0% | $322 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $107 | 0% | $107 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $61 | 0% | $61 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $29 | 0% | $29 |
| X-Ray - Complete Intraoral Series | $156 | 0% | $156 |
| X-Ray - Four Images, Bitewings | $76 | 0% | $76 |
| X-Ray - Intraoral, Periapical Radiographic Image | $39 | 0% | $39 |
| X-Ray - Two Images, Bitewings | $54 | 0% | $54 |
| X-Ray - Whole Mouth from Outside Mouth | $138 | 0% | $138 |
