| Dental Cleaning - Adult | $107 | 0% | $107 |
| Dental Cleaning - Child | $97 | 0% | $97 |
| Dental Exam - Comprehensive | $102 | 0% | $102 |
| Dental Exam - Periodic, Established Patient | $50 | 0% | $50 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $189 | 0% | $189 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $342 | 0% | $342 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | 0% | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $167 | 0% | $167 |
| Dental Filling - White (Resin): One Surface, Posterior | $189 | 0% | $189 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $342 | 0% | $342 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $205 | 0% | $205 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $263 | 0% | $263 |
| Flouride - Topical Varnish Application | $57 | 0% | $57 |
| Fluoride - Topical Application | $51 | 0% | $51 |
| Maintenance Therapy - Periodontal | $153 | 0% | $153 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $158 | 0% | $158 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $276 | 0% | $276 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $89 | 0% | $89 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $70 | 0% | $70 |
| Tooth Extraction - Elevation and/or Forceps Removal | $214 | 0% | $214 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $30 | 0% | $30 |
| X-Ray - Complete Intraoral Series | $201 | 0% | $201 |
| X-Ray - Four Images, Bitewings | $72 | 0% | $72 |
| X-Ray - Intraoral, Periapical Radiographic Image | $38 | 0% | $38 |
| X-Ray - Two Images, Bitewings | $59 | 0% | $59 |
| X-Ray - Whole Mouth from Outside Mouth | $131 | 0% | $131 |
