| Dental Cleaning - Adult | $142 | 0% | $142 |
| Dental Exam - Comprehensive | $126 | 0% | $126 |
| Dental Exam - Periodic, Established Patient | $69 | 0% | $69 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $240 | 0% | $240 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $374 | 0% | $374 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $294 | 0% | $294 |
| Dental Filling - White (Resin): One Surface, Posterior | $240 | 0% | $240 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $370 | 0% | $370 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $269 | 0% | $269 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $294 | 0% | $294 |
| Flouride - Topical Varnish Application | $65 | 0% | $65 |
| Maintenance Therapy - Periodontal | $193 | 0% | $193 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $92 | 0% | $92 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $341 | 0% | $341 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | 0% | $101 |
| X-Ray - Complete Intraoral Series | $197 | 0% | $197 |
| X-Ray - Four Images, Bitewings | $84 | 0% | $84 |
| X-Ray - Intraoral, Periapical Radiographic Image | $44 | 0% | $44 |
| X-Ray - Two Images, Bitewings | $89 | 0% | $89 |
