| Dental Cleaning - Adult | $129 | 0% | $129 |
| Dental Cleaning - Child | $118 | 0% | $118 |
| Dental Exam - Comprehensive | $99 | 0% | $99 |
| Dental Exam - Periodic, Established Patient | $68 | 0% | $68 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $185 | 0% | $185 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $227 | 0% | $227 |
| Dental Filling - White (Resin): One Surface, Anterior | $247 | 0% | $247 |
| Dental Filling - White (Resin): One Surface, Posterior | $257 | 0% | $257 |
| 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 | $334 | 0% | $334 |
| Flouride - Topical Varnish Application | $45 | 0% | $45 |
| Maintenance Therapy - Periodontal | $175 | 0% | $175 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $89 | 0% | $89 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $315 | 0% | $315 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $101 | 0% | $101 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $71 | 0% | $71 |
| Tooth Extraction - Elevation and/or Forceps Removal | $191 | 0% | $191 |
| X-Ray - Complete Intraoral Series | $186 | 0% | $186 |
| X-Ray - Four Images, Bitewings | $92 | 0% | $92 |
| X-Ray - Intraoral, Periapical Radiographic Image | $41 | 0% | $41 |
| X-Ray - Two Images, Bitewings | $63 | 0% | $63 |
