| Dental Cleaning - Adult | $110 | 0% | $110 |
| Dental Cleaning - Child | $86 | 0% | $86 |
| Dental Exam - Comprehensive | $105 | 0% | $105 |
| Dental Exam - Periodic, Established Patient | $61 | 0% | $61 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $208 | 0% | $208 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $326 | 0% | $326 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $265 | 0% | $265 |
| Dental Filling - White (Resin): One Surface, Anterior | $212 | 0% | $212 |
| Dental Filling - White (Resin): One Surface, Posterior | $219 | 0% | $219 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $343 | 0% | $343 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $254 | 0% | $254 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $279 | 0% | $279 |
| Flouride - Topical Varnish Application | $56 | 0% | $56 |
| Fluoride - Topical Application | $51 | 0% | $51 |
| Maintenance Therapy - Periodontal | $164 | 0% | $164 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $89 | 0% | $89 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $306 | 0% | $306 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | 0% | $71 |
| Tooth Extraction - Elevation and/or Forceps Removal | $225 | 0% | $225 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $24 | 0% | $24 |
| X-Ray - Complete Intraoral Series | $215 | 0% | $215 |
| X-Ray - Four Images, Bitewings | $80 | 0% | $80 |
| X-Ray - Intraoral, Periapical Radiographic Image | $36 | 0% | $36 |
| X-Ray - Two Images, Bitewings | $56 | 0% | $56 |
| X-Ray - Whole Mouth from Outside Mouth | $135 | 0% | $135 |
