| Dental Cleaning - Adult | $110 | 0% | $110 |
| Dental Cleaning - Child | $87 | 0% | $87 |
| Dental Exam - Comprehensive | $102 | 0% | $102 |
| Dental Exam - Periodic, Established Patient | $58 | 0% | $58 |
| Dental Filling - Silver (Amalgam): One Surface, Primary or Permanent | $226 | 0% | $226 |
| Dental Filling - Silver (Amalgam): Three Surfaces, Primary or Permanent | $347 | 0% | $347 |
| Dental Filling - Silver (Amalgam): Two Surfaces, Primary or Permanent | $263 | 0% | $263 |
| Dental Filling - White (Resin): One Surface, Anterior | $184 | 0% | $184 |
| Dental Filling - White (Resin): One Surface, Posterior | $210 | 0% | $210 |
| Dental Filling - White (Resin): Three Surfaces, Posterior | $362 | 0% | $362 |
| Dental Filling - White (Resin): Two Surfaces, Anterior | $226 | 0% | $226 |
| Dental Filling - White (Resin): Two Surfaces, Posterior | $289 | 0% | $289 |
| Fluoride - Topical Application | $43 | 0% | $43 |
| Maintenance Therapy - Periodontal | $158 | 0% | $158 |
| Orthodontic Treatment - Periodic Visit, Part of a Contract | $68 | 0% | $68 |
| Plaque and Tartar Removal - Around Teeth and Gums, Per Quadrant | $284 | 0% | $284 |
| Problem Focused Evaluation - Limited to a Specific Oral Health Problem or Complaint | $97 | 0% | $97 |
| Sealant - Placed on Tooth Surface to Prevent Decay | $63 | 0% | $63 |
| Tooth Extraction - Elevation and/or Forceps Removal | $231 | 0% | $231 |
| X-Ray - Additional Image of Tooth from Crown to Root from Inside Mouth | $38 | 0% | $38 |
| X-Ray - Complete Intraoral Series | $152 | 0% | $152 |
| X-Ray - Four Images, Bitewings | $79 | 0% | $79 |
| X-Ray - Intraoral, Periapical Radiographic Image | $42 | 0% | $42 |
| X-Ray - Two Images, Bitewings | $56 | 0% | $56 |
| X-Ray - Whole Mouth from Outside Mouth | $147 | 0% | $147 |
