| Dental Cleaning - Adult | $121 | 0% | $121 |
| Dental Cleaning - Child | $74 | 0% | $74 |
| Dental Exam - Comprehensive | $121 | 0% | $121 |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $231 | 0% | $231 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $415 | 0% | $415 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $284 | 0% | $284 |
| Dental Filling - White (Resin): One Surface, Anterior | $231 | 0% | $231 |
| Dental Filling - White (Resin): One Surface, Posterior | $231 | 0% | $231 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $415 | 0% | $415 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $252 | 0% | $252 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $284 | 0% | $284 |
| Flouride - Topical Varnish Application | $47 | 0% | $47 |
| Maintenance Therapy - Periodontal | $147 | 0% | $147 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $143 | 0% | $143 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $244 | 0% | $244 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $134 | 0% | $134 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $22 | 0% | $22 |
| X-Ray - Complete Intraoral Series | $147 | 0% | $147 |
| X-Ray - Four Images, Bitewings | $69 | 0% | $69 |
| X-Ray - Intraoral, Periapical Radiographic Image | $34 | 0% | $34 |
| X-Ray - Two Images, Bitewings | $51 | 0% | $51 |
| X-Ray - Whole Mouth from Outside Mouth | $121 | 0% | $121 |
